PurposeThe number of cancer survivors worldwide is growing, with over 15.5 million cancer survivors in the United States alone—a figure expected to double in the coming decades. Cancer survivors face unique health challenges as a result of their cancer diagnosis and the impact of treatments

Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable

Multiple organizations around the world have issued evidence-based exercise guidance for patients with cancer and cancer survivors. Recently, the American College of Sports Medicine has updated its exercise guidance for cancer prevention as well as for the prevention and treatment of a variety of cancer health-related outcomes (eg, fatigue, anxiety, depression, function, and quality of life). Despite these guidelines, the majority of people living with and beyond cancer are not regularly physically active. Among the reasons for this is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. The authors propose using the American College of Sports Medicine's Exercise Is Medicine initiative to address this practice gap. The simple proposal is for clinicians to assess, advise, and refer patients to either home-based or community-based exercise or for further evaluation and intervention in outpatient rehabilitation. To do this will require care coordination with appropriate professionals as well as change in the behaviors of clinicians, patients, and those who deliver the rehabilitation and exercise programming. Behavior change is one of many challenges to enacting the proposed practice changes. Other implementation challenges include capacity for triage and referral, the need for a program registry, costs and compensation, and workforce development. In conclusion, there is a call to action for key stakeholders to create the infrastructure and cultural adaptations needed so that all people living with and beyond cancer can be as active as is possible for them.

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Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer.

The Exercise and Sports Science Australia position statement: Exercise medicine in cancer management

Background: Recommendations for improved survival after cancer through physical activity (PA) exist, although the evidence is still emerging. Our primary objective was to conduct a systematic review and meta-analysis of the association between prediagnosis and postdiagnosis PA and survival (cancer-specific, all-cause, and cardiovascular disease mortality) for all cancers and by tumor site. Secondary objectives were to examine the associations within population subgroups, by PA domain, and to determine the optimal dose of PA related to survival. 
Methods: PubMed, EMBASE, and SportsDiscus databases were searched from inception to November 1, 2018. DerSimonian-Laird random-effects models were used to estimate the summary hazard ratios (HRs) and 95% confidence intervals (CI) for primary and secondary analyses and to conduct dose-response analyses. 
Results: Evidence from 136 studies showed improved survival outcomes with highest vs lowest levels of prediagnosis or postdiagnosis total or recreational PA for all-cancers combined (cancer specific mortality: HR = 0.82, 95% CI = 0.79 to 0.86, and HR = 0.63, 95% CI = 0.53 to 0.75, respectively) as well as for 11 specific cancer sites. For breast and colorectal cancers, greater reductions were observed for postdiagnosis PA (HR = 0.58-0.63) compared with prediagnosis PA (HR = 0.80-0.86) for cancer-specific and all-cause mortality. Survival benefits through PA were observed in most subgroups (within sex, body mass index, menopausal status, colorectal subtypes, and PA domain) examined. Inverse dose-response relationships between PA and breast cancer-specific and all-cause mortality were observed, with steep reductions in hazards to 10-15 metabolic equivalent hours per week. 
Conclusion: Higher prediagnosis and postdiagnosis levels of PA were associated with improved survival outcomes for at least 11 cancer types, providing support for global promotion of PA guidelines following cancer.

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Physical Activity and Mortality in Cancer Survivors: A Systematic Review and Meta-Analysis

Guidelines promote high quality cancer care. Rehabilitation recommendations in oncology guidelines have not been characterized and may provide insight to improve integration of rehabilitation into oncology care. This report was developed as a part of the World Health Organization (WHO) Rehabilitation 2030 initiative to identify rehabilitation-specific recommendations in guidelines for oncology care. A systematic review of guidelines was conducted. Only guidelines published in English, for adults with cancer, providing recommendations for rehabilitation referral and assessment or interventions between 2009 and 2019 were included. 13840 articles were identified. After duplicates and applied filters, 4897 articles were screened. 69 guidelines were identified with rehabilitation-specific recommendations. Thirty-seven of the 69 guidelines endorsed referral to rehabilitation services but provided no specific recommendations regarding assessment or interventions. Thirty-two of the 69 guidelines met the full inclusion criteria and were assessed using the AGREE II tool. Twenty-one of these guidelines achieved an AGREE II quality score of ≥ 45 and were fully extracted. Guidelines exclusive to pharmacologic interventions and complementary and alternative interventions were excluded. Findings identify guidelines that recommend rehabilitation services across many cancer types and for various consequences of cancer treatment signifying that rehabilitation is a recognized component of oncology care. However, these findings are at odds with clinical reports of low rehabilitation utilization rates suggesting that guideline recommendations may be overlooked. Considering that functional morbidity negatively affects a majority of cancer survivors, improving guideline concordant rehabilitative care could have substantial impact on function and quality of life among cancer survivors.

https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.3322/caac.21639

A systematic review of rehabilitation and exercise recommendations in oncology guidelines

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).

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Clinical Oncology Society of Australia position statement on exercise in cancer care

Exercise as part of routine cancer care

To examine the feasibility of using the Mayo Clinic’s Early Screen for Discharge Planning (ESDP) tool in determining its predictive ability in an inpatient oncology hospital setting for variables including length of stay (LOS), discharge destination, and readmission risk. A prospective observational study was conducted at a metropolitan tertiary cancer centre in Melbourne, Australia. The ESDP score, along with patient outcomes and characteristics, were collected to examine the relationships between positive and negative ESDP scores and patient outcomes. A total of 136 participants met inclusion criteria for this study. The proportion with positive ESDP scores was greater in those with unplanned hospital admissions compared with planned admissions (χ2(1, n = 136) = 3.94, p = 0.047). The ESDP status was not a significant predictor of oncology hospital LOS (rpb = 0.116, p = 0.178); however, the ESDP scores did predict discharge destination (χ2(2, n = 136) = 20.22, p < .001). Those re-admitted within 14 days were more likely to have negative ESDP scores than those not readmitted within this time period (χ2(1, n = 136) = 5.22, p = 0.022). Those with positive ESDP scores received a greater number of hospital services whilst admitted than those with negative scores (rpb = 0.388, p < .001) and were more likely to receive particular types of services. The findings from this study suggest that the ESDP tool could be useful in an adult inpatient oncology population in a hospital with defined specialised hospital discharge planning services (SHDCPS). The ESDP may be beneficial for early identification of service types likely to be required in care and likely discharge destination, both of which can assist discharge planning (DP); however, the ESDP was not useful for predicting LOS or readmission risk in the adult inpatient oncology population without a SHDCPS model in place.

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Utility of Mayo Clinic’s early screen for discharge planning tool for predicting patient length of stay, discharge destination, and readmission risk in an inpatient oncology cohort

Cancer-related sarcopenia is a complex condition; however, no cancer-specific clinical model is available to guide clinical practice. This study aims to (1) develop an evidence-based care pathway for the management of cancer-related sarcopenia (“sarc-pathway”) and (2) pilot test the feasibility (reach, intervention fidelity, patient and clinician acceptability) of the sarc-pathway in an inpatient cancer ward. The sarc-pathway was developed using a care pathway format and informed by the current literature. Patients admitted to a 32-bed inpatient cancer ward were recruited to receive sarc-pathway care and the feasibility outcomes were assessed. Of the 317 participants admitted, 159 were recruited over 3.5-months (median age 61 years; 56.0% males). Participant consent was high (99.4% of those approached) and 30.2% were at risk of/had sarcopenia. The sarc-pathway screening, assessment and treatment components were delivered as intended; however, low completion of clinical assessment measures were observed for muscle mass (bioimpedance spectroscopy, 20.5%) and muscle function (5-times chair stand test, 50.0%). The sarc-pathway was demonstrated to be acceptable to patients and multidisciplinary clinicians. In an inpatient cancer ward, the sarc-pathway is a feasible and acceptable clinical model and method to deliver and adhere to the sarcopenia clinical parameters specified, albeit with further exploration of appropriate clinical assessment measures.

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Lucy Bucci

Papers

Clinical Oncology Society of Australia position statement on exercise in cancer care

Exercise as part of routine cancer care

Utility of Mayo Clinic’s early screen for discharge planning tool for predicting patient length of stay, discharge destination, and readmission risk in an inpatient oncology cohort

Development and Feasibility of an Inpatient Cancer-Related Sarcopenia Pathway at a Major Cancer Centre