Clinical Oncology Society of Australia position statement on exercise in cancer care
Introduction: Clinical research has established exercise as a safe and effective intervention to counteract the adverse physical and psychological effects of cancer and its treatment. This article summarises the position of the Clinical Oncology Society of Australia (COSA) on the role of exercise in cancer care, taking into account the strengths and limitations of the evidence base. It provides guidance for all health professionals involved in the care of people with cancer about integrating exercise into routine cancer care.
Main recommendations: COSA calls for:
- exercise to be embedded as part of standard practice in cancer care and to be viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment;
- all members of the multidisciplinary cancer team to promote physical activity and recommend that people with cancer adhere to exercise guidelines; and
- best practice cancer care to include referral to an accredited exercise physiologist or physiotherapist with experience in cancer care.
Changes in management as a result of the guideline: COSA encourages all health professionals involved in the care of people with cancer to:
- discuss the role of exercise in cancer recovery;
- recommend their patients adhere to exercise guidelines (avoid inactivity and progress towards at least 150 minutes of moderate intensity aerobic exercise and two to three moderate intensity resistance exercise sessions each week); and
- refer their patients to a health professional who specialises in the prescription and delivery of exercise (ie, accredited exercise physiologist or physiotherapist with experience in cancer care).
The Clinical Oncology Society of Australia (COSA) is the peak national body representing multidisciplinary health professionals whose work encompasses cancer control and care. Its members are doctors, nurses, scientists and allied health professionals involved in the clinical care of people with cancer. COSA is affiliated with, and provides medical and scientific advice to, Cancer Council Australia. COSA has developed a statement outlining its position on the role of exercise in cancer care
The term physical activity applies to any movement produced by skeletal muscles that requires the body to exert energy. Exercise is structured physical activity for the purpose of conditioning the body to improve health and fitness. To maximise the therapeutic potential of exercise, well established principles of training (including specificity, progression, overload, individualisation) should be applied and operationalised using the FITT formula: frequency (number of exercise sessions), intensity (how hard per session), time (session duration), and type (exercise modality)
Clinical research has established exercise as a safe and effective intervention to counteract many of the adverse physical and psychological effects of cancer and its treatment. To date, the strongest evidence exists for improving physical function (including aerobic fitness, muscular strength and functional ability), attenuating cancer-related fatigue, alleviating psychological distress and improving quality of life across multiple general health and cancer-specific domains.
Emerging evidence highlights that regular exercise before, during and following cancer treatment decreases the severity of other adverse side effects and is associated with reduced risk of developing new cancers and comorbid conditions such as cardiovascular disease, diabetes and osteoporosis.3,4 Moreover, epidemiological research suggests that being physically active provides a protective effect against cancer recurrence, cancer-specific mortality and all-cause mortality for some types of cancer (research has predominantly focused on breast, colorectal and prostate cancers). These findings have set the scene for a number of clinical trials, which are currently underway to rigorously evaluate the effects of exercise on cancer survival.
The convincing body of epidemiological and clinical trial evidence on the benefits of exercise has led to the endorsement of exercise guidelines for people with cancer by major organisations internationally. These guidelines largely mirror guidelines for the general population. Despite this advice being widely disseminated by government and non-government cancer organisations, the majority of Australians with cancer do not meet these recommended targets. Reports indicate that 60–70% of people with cancer do not meet aerobic exercise guidelines and it is estimated that 80–90% do not meet resistance exercise guidelines.Thus, although many people with cancer have indicated a desire to participate in appropriately designed and supervised exercise programs, only a minority are engaging in sufficient levels of exercise.
The COSA position statement on exercise in cancer care outlines the Society’s position on exercise recommendations, taking into account the strengths and limitations of the epidemiological and clinical trials evidence base.
The key points are:
being physically active and exercising regularly are important for the health, function, quality of life and, potentially, survival of people with cancer;
the majority of people with cancer do not meet exercise recommendations;
people with cancer express a desire to become and to stay sufficiently active but need advice and support to do so; and
to maximise safety and therapeutic effect, exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with a focus on transitioning to ongoing self-managed exercise.
Exercise should be embedded as part of standard practice in cancer care and viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment
The level of scientific evidence now available substantiates the inclusion of exercise as a component of routine cancer care. The body of scientific literature, including many randomised controlled trials involving thousands of cancer patients, provides evidence that exercise is an important adjunct therapy in the management of cancer. People with cancer who exercise experienced fewer or less severe adverse effects; thus, it is likely that incorporating exercise within the cancer treatment paradigm will reduce disease burden.While epidemiological evidence suggests that patients who exercise following a diagnosis of cancer have a lower relative risk of cancer mortality and recurrence,randomised controlled trial data are required to determine the effect of exercise on survival outcomes.
All members of the multidisciplinary cancer team should promote physical activity and recommend people with cancer adhere to exercise guidelines
COSA calls for evidence-based exercise guidelines to be implemented by all health professionals involved in the care of people with cancer. Specifically, all members of the cancer care team should advise their patients to:
avoid inactivity and be as physically active as current abilities and conditions allow; and
progress towards and, once achieved, maintain participation in at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic exercise each week, and two to three resistance exercise sessions each week involving moderate to vigorous intensity exercises targeting the major muscle groups.
In line with evidence-based guidelines, COSA identifies that these recommendations should be tailored to the individual’s abilities, noting that specific exercise programming adaptations may be required based on disease- and treatment-related adverse effects, anticipated disease trajectory and the patient’s health status.
Best practice cancer care should include referral to an accredited exercise physiologist or physiotherapist with experience in cancer care
COSA recognises that accredited exercise physiologists and physiotherapists, as university qualified allied health professionals specialising in the prescription and delivery of exercise, are the most appropriate practitioners to implement exercise guidelines with cancer patients. While not all people with cancer will require ongoing supervision, these practitioners will allow for exercise to be prescribed in line with evidence-based guidelines. Specifically, exercise physiologists and physiotherapists with experience in cancer care will appropriately tailor exercise recommendations to the individual needs of each patient. Such practitioners are also trained to educate patients in behaviour change techniques to allow for positive long term exercise behaviour.