Author: Karen Kane McDonnell PhD, RN, Associate Professor, Co-Director, Cancer Survivorship Center, College of Nursing, University of South California, United States
Physical activity (PA) is an important behavior for the prevention and management of numerous acute and chronic diseases (Courneya & Friedenreich, 2010). The number of cancer survivors is rising worldwide, propelled by advances in early detection and treatment and the aging of the population. The predicted global cancer burden is expected to exceed 27 million new cancer cases per year by 2040, a 50% increase in the estimated number of new cancer cases in 2018 (Wild, Weiderpass, & Stewart, 2020). Many cancer survivors are motivated to seek information and advice about PA to improve their response to treatment, facilitate recovery, reduce their risk of recurrence, and improve their quality of life (QOL) (Rock et al., 2012).
Exercise is defined as “a physical activity causing an increase in energy expenditure and involving a planned or structured movement of the body performed in a systematic manner in terms of frequency, intensity, and duration, and designed to maintain or enhance health-related outcomes” (Campbell et al., 2019). For over five decades, PA has been tested as an intervention strategy to help survivors with cancer prepare for, manage side effects of, and recover after treatments. The field that considers PA and cancer survivorship together—exercise oncology—has exploded. The literature now contains thousands of studies about the effects of PA in survivors of cancer; these studies have, in turn, generated dozens of systematic reviews, several sets of international guidelines, and calls for the integration of PA programs into clinical and community cancer care (Courneya, 2017).
PA recommendations vary across the cancer continuum and remain an important area of research. PA interventions have been shown effective in treating both the physical and psychological impairments associated with some cancers and their treatments, with potential for improving overall outcomes. Despite mounting evidence of its benefits, PA is still underutilized due to lack of awareness and knowledge among health-care providers, survivors of cancer, and survivors’ family members (who are often also caregivers) (Maddocks, 2020).
International Guidelines on Exercise and Cancer
Several organizations have put forth guidelines that include specific PA recommendations for cancer survivors; these guidelines include the American College of Sports Medicine’s (ACSM) International Multidisciplinary Roundtable on Exercise and Cancer (Campbell et al, 2019); Exercise and Sports Science Australia’s (ESSA) exercise and cancer position statement (Hayes, Newton, Spence, & Galvão, 2019); and the American Cancer Society’s (ACS) Nutrition and Physical Activity Guidelines for Cancer Survivors, (Rock et al., 2012). See Table 1.
In 2018, the second ACSM Roundtable on Exercise and Cancer was assembled to advance their previous recommendations beyond public health guidelines and progress toward prescriptive programs specific to cancer type, treatment, and outcomes (Campbell et al., 2019). The Roundtable reaffirmed that PA, exercise testing, and training are generally safe for survivors of cancer and that every survivor should avoid inactivity. Also, the group determined that adequate evidence exists that specific doses of aerobic, resistance, or combined aerobic-plus-resistance training could improve common cancer-related health challenges, including anxiety, depression, fatigue, reduced physical functioning, and health-related QOL.
ESSA incorporated current scientific evidence, coupled with clinical experience and exercise science principles, to update its position statement on cancer-specific exercise prescriptions in 2019 (Hayes et al., 2019). ESSA recommends a process for developing targeted exercise prescriptions. The ESSA framework includes patient assessment, determination of coexisting health issues, identification of patient capacity and intervention suitability, creation of an exercise prescription according to survivor-driven exercise-related goals, and reassessment.
The ACS’s guidelines address both PA and nutrition for the full continuum of cancer survivors, including those in treatment and recovery, long-term disease-fee living, living with stable disease, and living with advanced disease (Rock et al., 2012). The ACS notes that it is important to remember that survivors across the entire cancer survivorship continuum have different PA needs and challenges, including unique motives, barriers, and preferences.
Summary: The Evidence and Implications for Practice
Overall, evidence exists supporting the implementation of an exercise prescription for survivors of cancer due to its role in reducing morbidity, improving day-to-day physical function and QOL, and improving the potential for survival—all with a low risk of harm. However, the strength of the evidence in relation to exercise safety, feasibility, and benefit depends on cancer type and outcome of interest. While for some survivors, multimodal, moderate- to high-intensity exercise will be appropriate, others will not be able to tolerate such PA levels. Because of the wide-ranging variances across the cancer continuum, there is no set prescription and total weekly dosage of PA that is considered evidence-based for all survivors. Consequently, PA prescriptions need to be targeted and individualized according to survivor- and cancer-specific considerations (Campbell et all., 2019; Hayes et al., 2019; Rock et al., 2012).
For survivors to maintain or improve physical function and possibly reduce cancer-related toxicities, oncology nurses must be prepared to discuss the short- and long-term benefits of PA (Mustian, Lin, Cole, Loh, & Magnuson, 2020). Ideally, oncology providers should partner closely with exercise professionals (like physical therapists or certified cancer exercise trainers) to help identify risks and contraindications that may affect exercise safety and tolerance, and to create individualized exercise prescriptions to meet the unique needs of survivors with various cancer types and disease stages. Lack of knowledge, resource funding, facilities, programs, qualified staff, and exercise specialists in cancer care may be barriers in many settings.
With international guidelines as a springboard, we urge oncology nurses to initiate discussion of PA recommendations for survivors with their colleagues and regularly incorporate those recommendations into their care plans. In addition, more exercise intervention studies with diverse groups of survivors in various settings, including the home, community, and hospital, are needed to grow the evidence base and gain widespread acceptance among professional and the lay communities.
Campbell, K. L., Winters-Stone, K. M., Wiskemann, J., May, A. M., Schwartz, A. L., Courneya, K. S., . . . Schmitz, K. H. (2019). Exercise guidelines for cancer survivors: Consensus statement from international multidisciplinary roundtable. Medicine and Science in Sports and Exercise, 51(11), 2375–2390.
Courneya, K. S. (2017). Exercise guidelines for cancer survivors: Are fitness and quality-of-life benefits enough to change practice? Current Oncology, 24(1), 8.
Courneya, K. S., & Friedenreich, C. M. (2010). Physical activity and cancer: An introduction. In K. S. Courneya & C. M. Friedenreich (Eds.), Physical Activity and Cancer (pp. 1–10). Berlin, Germany: Springer.
Hayes, S. C., Newton, R. U., Spence, R. R., & Galvão, D. A. (2019). The Exercise and Sports Science Australia position statement: Exercise medicine in cancer management. Journal of Science and Medicine in Sport, 22(11), 1175–1199.
Maddocks, M. (2020). Physical activity and exercise training in cancer patients. Clinical Nutrition ESPEN, 40, 1–6.
Mustian K., Lin, P. J., Cole, C., Loh, K. P., & Magnuson, A. (2020). Exercise and the older cancer survivor. In M. Extermann (Ed.), Geriatric Oncology (pp. 917–938). Berlin, Germany: Springer.
Rock, C. L., Doyle, C., Demark‐Wahnefried, W., Meyerhardt, J., Courneya, K. S., Schwartz, A. L., . . . Gansler, T. (2012). Nutrition and physical activity guidelines for cancer survivors. CA: A Cancer Journal for Clinicians, 62(4), 242–274.
Wild, C. P., Weiderpass, E., & Stewart, B. W. (2020). World cancer report: Cancer research for cancer prevention. Lyon, France: International Agency for Research on Cancer [IARC]. Retrieved from the IARC website: http://publications.iarc.fr/586.
Disclosure: Karen Kane McDonnell is supported by the American Cancer Society under award number MRSG-17-152-01 and the Bristol Myers Squibb Foundation. The content is solely the responsibility of the author and does not represent the official views of the American Cancer Society or the Bristol Myers Squibb Foundation.