“There is clear evidence that patients are more likely to exercise if their oncologist tells them to do so,” reported representatives from 17 organizations participating in the Second Roundtable on Exercise and Cancer Prevention and Control. In an article published in CA: A Cancer Journal for Clinicians,1 the authors call on oncology clinicians to assess physical activity of patients with cancer, to advise them on desired levels of physical activity, and to refer patients to appropriate exercise programs or to other health professionals. “Preserving activity and functional ability is integral to cancer care, and oncology clinicians are key to providing these referrals,” the roundtable participants concluded.
The organizations represented at the roundtable discussion included the National Comprehensive Cancer Network, American Cancer Society, American College of Sports Medicine (ACSM), and other groups concerned with exercise physiology and rehabilitation.
Two other articles, one presenting a systematic review of the evidence that physical activity can reduce cancer risk and improve survival following a cancer diagnosis, and the other presenting specific evidence-based exercise guidelines to improve cancer-related health outcomes, were published earlier this year in Medicine and Science in Sports and Exercise.2,3 Overall, the review of evidence reaffirmed earlier conclusions that exercise training and testing were generally safe for cancer survivors and that every survivor should “avoid inactivity.”4
Aerobics and Strength Training
Kathryn H. Schmitz, PhD, MPH
“Until now, the guidance that we have given people for exercise during and after cancer treatment period has been very much following the public health guidelines, which is 150 minutes a week, twice-a-week strength training, and flexibility on most days,” Kathryn H. Schmitz, PhD, MPH, lead author of the most recent report, told The ASCO Post. “But that was not truly evidence-based for patients with cancer. It was more of an expert opinion.” Dr. Schmitz is Professor, Department of Public Health Sciences and Department of Physical Medicine and Rehabilitation at Penn State Cancer Institute in Hershey, Pennsylvania, and Immediate Past President of the ACSM.
The new evidence-based recommendations for patients with cancer call for specific exercise prescriptions for distinct outcomes. For example, if the goal is to address fatigue, the recommendation is for 30 minutes of moderately intense aerobic activity three times per week and 20 to 30 minutes of resistance or strength training exercise two times per week. The specific recommendation varies according to the outcome of interest, as well as the patient’s overall status and current level of activity, highlighting the important role of oncology clinicians who see these patients regularly.
Assess, Advise, Refer
Using elements from the ACSM’s Exercise Is Medicine initiative, the roundtable recommends that “at the very least, oncology clinicians should: 1. Assess current physical activity at regular intervals; 2. Advise patients with cancer on their current and desired level of physical activity and convey the message that moving matters; and 3. Refer patients to appropriate exercise programs or to the appropriate health-care professionals who can evaluate and refer to exercise.”
As the authors make a point of clarifying, “Oncology clinicians are not expected to give specifics of exercise prescriptions” or “to do extensive screening and triage.” Dr. Schmitz also stressed that point: “One of the things we don’t want is for oncology clinicians to have to take on the burden of clarifying how to do the exercise. That is a very important point.”
“One of the things we don’t want is for oncology clinicians to have to take on the burden of clarifying how to do the exercise.”— Kathryn H. Schmitz, PhD, MPH
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Citing the analogy of an oncology clinician making a referral for psychosocial distress, she said that “oncologists are encouraged to ask about psychosocial distress; they are not asked to be psychologists.” Similarly, oncologists are being asked to “refer to physical therapists or to known exercise programs that work with patients with cancer, like the LiveSTRONG program, or to clinical exercise physiology professionals, in order for those folks to do their job, which is to help patients understand how going through treatment is going to alter a person’s capacity for exercise from one week to the next.”
Rely on Registry
Oncologists can use the registry developed by the roundtable to refer patients. The registry “is updated regularly and has added 30 to 40 programs since the paper was published,” Dr. Schmitz reported. “We are currently seeking funding so that the registry is audited regularly” to assure referring physicians that the referrals are to licensed and/or certified professionals and organizations and to ensure that patients have beneficial experiences. The registry is available online at www.exerciseismedicine.org/movingthroughcancer.
The registry also provides links to Moving Through Cancer patient education materials, providing guidance for patients with cancer seeking to become more physically active. The Moving Through Cancer initiative was started by a presidential task force when Dr. Schmitz served as ACSM President.
Regular Intervals
The report notes the importance of repeating the three steps—assess, advise, and refer—at regular intervals. “We originally said, ‘Do it every time,’ because that is what we would really like to have happen,” Dr. Schmitz explained.
“Physical activity is the number one treatment for cancer-related fatigue. There is not a drug on the market that works better than exercise for cancer-related fatigue.”— Kathryn R. Schmitz, PhD, MPH
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“Understand that this work occurred in collaboration with 17 different partnering organizations and 40 seasoned professionals who came together to write these three papers,” she continued. “Some of the more clinically oriented partnering organizations objected to assess, advise, refer at every encounter. I think the objection was fair because at present, there is a requirement that psychosocial distress be assessed at major shifts along the journey of cancer treatment. Those clinical collaborators thought it was asking too much for physical activity to be required at every visit if psychosocial distress was not.”
She added, “Ideally, though, it would be every visit. One of problems with not having it at every visit, is then deciding when to bring it up. That is an issue, but I agree, we can’t place physical activity higher than psychosocial distress, even though physical activity would assist with psychosocial distress.”
Time Constraints
Among reasons oncology clinicians are currently not encouraging physical activity for patients with cancer are a lack of awareness, uncertainty about the value of exercise and available programs, and a belief that referrals to exercise programs are not within the scope of practice for oncology clinicians.
Dr. Schmitz acknowledged that oncologists usually only have 15 to 20 minutes during a patient’s visit to discuss a host of issues in accordance with treatment guidelines from professional organizations. “They have so many things that they are supposed to be covering in that 15 minutes, and we are asking them to do more,” she said. Perhaps it is not the oncologists, but nurses and medical assistants who should be making the referrals for exercise. “It is not clear,” she said. “We need implementation science research to try to figure that out.”
Dealing With Side Effects
“Especially during treatment, patients are at risk of developing side effects that are a barrier to exercise,” the roundtable participants wrote. “Patients may underestimate how the treatment might affect their ability to exercise on their own. Also, current evidence indicates that exercise under supervision yields better outcomes.”
One of the earlier papers reported that there is a consensus that the benefit of exercise “had been consistently demonstrated” for the following cancer-related outcomes: anxiety, depressive symptoms, fatigue, health-related quality of life, lymphedema, and physical function.2 “Physical activity is the number 1 treatment for cancer-related fatigue,” Dr. Schmitz said. “There is not a drug on the market that works better than exercise for cancer-related fatigue.”
That paper also presents evidence-based prescriptions for frequency, intensity, time, and type of exercise to address cancer-related outcomes. “We’ve done a systematic review of 16 specific outcomes that are of importance to patients, their caregivers, and their doctors,” Dr. Schmitz noted, “and we are able to say about 8 of them, here is specifically how much exercise you need in order to have an effect on that.” Data do not currently exist to make specific recommendations for the other outcomes.
The Hurdles
“The simple proposal is for clinicians to assess, advise, and refer,” the roundtable participants wrote, but they also acknowledged that the proposal won’t be simple to accomplish, requiring care coordination and changes in behaviors.
“We have three foundational issues that we think need to happen in order for us to get from our current stage to our desired stage of assess, advise, and refer happening at all or many visits,” Dr. Schmitz explained.
The first issue is “awareness on the part of patients, caregivers, and oncology clinicians,” Dr. Schmitz said. “The second foundational element is programming and workforce. We understand that you can only make referrals when there is someone to refer to. So we need to increase the workforce of exercise and outpatient rehabilitation professionals who are prepared to receive the 1.7 million patients diagnosed with cancer every year, not to mention the 17 million survivors,” she added.
“Foundational element number 3 is policy,” Dr. Schmitz continued. Policy changes could include getting approval from the Centers for Medicare & Medicaid Services (CMS) for a code to enable coverage or accreditation requirements from professional organizations such as ASCO.
There are many options that need to be explored, but as noted by the roundtable participants, “Waiting to start referrals until the full infrastructure is in place misses the opportunity for a greater proportion of patients to become active through an admittedly imperfect infrastructure that currently exists.”
Activation and Advocacy
Dr. Schmitz and coauthors noted that patients with cancer and cancer survivors have a powerful voice, which they could use to advance efforts to develop more exercise and physical activity programs. “That is part of the work of Moving Through Cancer, to try to activate” patients with cancer and cancer survivors. Participants in the roundtable group believe “we will only get so far ourselves. We think we will get much farther if we can activate that incredible amount of energy from those hundreds of smaller cancer support and advocacy organizations across the United States that have a lot of grassroots support.”
There is now “more evidence to show why we should be exercising patients with cancer and survivors” than when cardiac rehabilitation following infarction was approved by CMS in the 1980s, Dr. Schmitz noted. She said that her goal is “is to make exercise as ubiquitous in cancer care as it is in cardiac disease, only better.” She aims for better because although most people polled will say they know that exercise is important to strengthen the heart after myocardial infarction, “less than 30% of people who should go to cardiac rehabilitation do go.”
DISCLOSURE: Dr. Schmitz reported no conflicts of interest.
REFERENCES
1. Schmitz KH, Campbell AM, Stuiver M, et al: Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA Cancer J Clin. October 16, 2019 (early release online).
2. Campbell KL, Winters-Stone KM, Wiskemann J, et al: Exercise guidelines for cancer survivors: Consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc 51:2375-2390, 2019.
3. Mctiernan A, Friedenreich CM, Katzmarzyk PT, et al: Physical activity in cancer prevention and survival: A systematic review. Med Sci Sports Exerc 51:1252-1261, 2019.
4. Schmitz KH, Courneya KS, Matthews C, et al: American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc 42:1409-1426, 2010.
