An exercise oncology clinical pathway: Screening and referral for personalized interventions
West Virginia University1, National Institutes of Health2, Louisiana State University3, Northern Arizona University4, American Physical Therapy Association5, Edinburgh Napier University6, Brigham and Women's Hospital7, University of Texas MD Anderson Cancer Center8, University of Pittsburgh9, Harvard University10, Mayo Clinic11, New York University12, Pennsylvania State University13, American Cancer Society14
TL;DR: This research highlights the need to understand more fully the role of emotion in the decision-making process and the role that emotion plays in the development of new treatments for depression.
Abstract: There are approximately 17 million cancer survivors living in the United States and by 2040 this estimate is predicted to increase to 26.1 million.1 Exercise provides a myriad of health benefits to individuals during and after cancer treatment by reducing treatment-related symptoms, improving functional status and quality of life, and lowering risk of disease recurrence.2,3 Despite the established benefits, an individual’s level of physical activity often decreases during treatment and does not return to pre-diagnosis levels after treatment completion.4,5 While exercise is regarded as safe and beneficial for individuals with cancer, promoting exercise for this population is complex. A patient-centered pathway is needed that can guide oncology and primary care professionals in efficient assessment of an individual’s condition and enable personalized referrals for exercise interventions that promote physical activity. The purpose of this manuscript is to provide a framework for clinical decision making that enables personalized condition assessment, risk stratification, and referral to optimal settings for exercise promotion for cancer survivors. Implementation strategies are also offered to support the integration of this model into an oncology clinical workflow.
With guidance from their medical provider, individuals are more likely to engage in exercise and maintain levels of physical activity during cancer treatments.6 However, the number of individuals with cancer who report receiving exercise-specific guidance from their health care providers is low.7 Of particular concern is the lack of knowledge and training among health care professionals about exercise prescription for this complex population.8
Citations
More filters
American Cancer Society1, Alberta Health Services2, Queensland University of Technology3, Harvard University4, University of British Columbia5, Oregon Health & Science University6, George Mason University7, National Institutes of Health8, Centers for Disease Control and Prevention9, Fox Chase Cancer Center10, Wingate University11, Pennsylvania State University12
TL;DR: There is consistent, compelling evidence that physical activity plays a role in preventing many types of cancer and for improving longevity among cancer survivors, although the evidence related to higher risk of melanoma demonstrates the importance of sun safe practices while being physically active.
Abstract: Introduction The American College of Sports Medicine convened an International Multidisciplinary Roundtable on Exercise and Cancer in March 2018 to evaluate and translate the evidence linking physical activity and cancer prevention, treatment, and control. This article discusses findings from the Roundtable in relation to the biologic and epidemiologic evidence for the role of physical activity in cancer prevention and survival. Results The evidence supports that there are a number of biologically plausible mechanisms, whereby physical activity can influence cancer risk, and that physical activity is beneficial for the prevention of several types of cancer including breast, colon, endometrial, kidney, bladder, esophageal, and stomach. Minimizing time spent in sedentary behavior may also lower risk of endometrial, colon and lung cancers. Conversely, physical activity is associated with higher risk of melanoma, a serious form of skin cancer. Further, physical activity before and after a cancer diagnosis is also likely to be relevant for improved survival for those diagnosed with breast and colon cancer; with data suggesting that postdiagnosis physical activity provides greater mortality benefits than prediagnosis physical activity. Conclusions Collectively, there is consistent, compelling evidence that physical activity plays a role in preventing many types of cancer and for improving longevity among cancer survivors, although the evidence related to higher risk of melanoma demonstrates the importance of sun safe practices while being physically active. Together, these findings underscore the importance of physical activity in cancer prevention and control. Fitness and public health professionals and health care providers worldwide are encouraged to spread the message to the general population and cancer survivors to be physically active as their age, abilities, and cancer status will allow.
387 citations
Walter Reed Army Institute of Research1, University of Pennsylvania2, American Cancer Society3, Queensland University of Technology4, University of British Columbia5, University of Alberta6, Naval Medical Center San Diego7, University of Nebraska Medical Center8, Mayo Clinic9, University of Kansas10, George Mason University11, Lund University12, Memorial Sloan Kettering Cancer Center13
TL;DR: A prospective surveillance model for physical rehabilitation and exercise that can be integrated with disease treatment to create a more comprehensive approach to survivorship health care is proposed.
Abstract: Free to read
Background: The current model of care for breast cancer is focused on disease treatment followed by ongoing recurrence surveillance. This approach lacks attention to the patients’ physical and functional well-being. Breast cancer treatment sequelae can lead to physical impairments and functional limitations. Common impairments include pain, fatigue, upper extremity dysfunction, lymphedema, weakness, joint arthralgia, neuropathy, weight gain, cardiovascular effects, and osteoporosis. Evidence supports prospective surveillance for early identification and treatment as a means to prevent or mitigate many of these concerns.
Purpose: This paper proposes a prospective surveillance model for physical rehabilitation and exercise that can be integrated with disease treatment to create a more comprehensive approach to survivorship health care. The goals of the model are to promote surveillance for common physical impairments and functional limitations associated with breast cancer treatment, to provide education to facilitate early identification of impairments, to introduce rehabilitation and exercise intervention when physical impairments are identified and to promote and support physical activity and exercise behaviors through the trajectory of disease treatment and survivorship.
Methods: The model is the result of a multi-disciplinary meeting of research and clinical experts in breast cancer survivorship and representatives of relevant professional and advocacy organizations.
Outcomes: The proposed model identifies time points during breast cancer care for assessment of and education about physical impairments. Ultimately, implementation of the model may influence incidence and severity of breast cancer treatment related physical impairments. As such, the model seeks to optimize function during and following treatment and positively influence a growing survivorship community.
180 citations
TL;DR: The authors include information on the relationship between health‐related behaviors and comorbidities, long‐term sequelae and patient‐reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations.
Abstract: The overall 5‐year relative survival rate for all cancers combined is now 68%, and there are over 16.9 million survivors in the United States. Evidence from laboratory and observational studies suggests that factors such as diet, physical activity, and obesity may affect risk for recurrence and overall survival after a cancer diagnosis. The purpose of this American Cancer Society guideline is to provide evidence‐based, cancer‐specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and cancer‐specific and overall mortality. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing American Cancer Society programs, health policy, and the media. Sources of evidence that form the basis of this guideline are systematic literature reviews, meta‐analyses, pooled analyses of cohort studies, and large randomized clinical trials published since 2012. Recommendations for nutrition and physical activity during cancer treatment, informed by current practice, large cancer care organizations, and reviews of other expert bodies, are also presented. To provide additional context for the guidelines, the authors also include information on the relationship between health‐related behaviors and comorbidities, long‐term sequelae and patient‐reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations. Approaches to meet survivors' needs are addressed as well as clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis.
137 citations
TL;DR: 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, at odds with clinical reports of low rehabilitation utilization rates suggesting that guideline recommendations may be overlooked.
Abstract: 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.
85 citations
TL;DR: The agenda of the newly formed Moving Through Cancer initiative is described, which has a primary objective of making exercise standard practice in oncology by 2029.
Abstract: LAY SUMMARY International evidence-based guidelines support the prescription of exercise for all individuals living with and beyond cancer. This article describes the agenda of the newly formed Moving Through Cancer initiative, which has a primary objective of making exercise standard practice in oncology by 2029.
42 citations
Cites background from "An exercise oncology clinical pathw..."
...Health care professionals need to be able to quickly screen using appropriate screening questionnaires and/or refer to health care providers (eg, physiatrists, physical therapists, or clinical exercise physiologists) who can assess basic functional ability using simple performance status measures to triage and refer patients to appropriate exercise oncology programs.(22) Knowledge building and awareness of exercise program components and evidence-based indications across the oncology workforce are needed to help facilitate comprehensive care....
[...]
References
More filters
TL;DR: In this article, a broad view of health behaviour causation, with the social and physical environment included as contributors to physical inactivity, particularly those outside the health sector, such as urban planning, transportation systems, and parks and trails, is presented.
3,063 citations
TL;DR: The roundtable concluded that exercise training is safe during and after cancer treatments and results in improvements in physical functioning, quality of life, and cancer-related fatigue in several cancer survivor groups, sufficient for the recommendation that cancer survivors follow the 2008 Physical Activity Guidelines for Americans.
Abstract: to physical functioning and quality of life are sufficient for the recommendation that cancer survivors follow the 2008 Physical Activity Guidelines for Americans, with specific exercise programming adaptations based on disease and treatment-related adverse effects. The advice to ‘‘avoid inactivity,’’ even in cancer patients with existing disease or undergoing difficult treatments, is likely helpful.
2,202 citations
"An exercise oncology clinical pathw..." refers background in this paper
...Exercise provides a myriad of health benefits to individuals during and after cancer treatment by reducing treatment-related symptoms, improving functional status and quality of life, and lowering the risk of disease recurrence.(2,3) Despite the established benefits, an individual’s level of physical activity often decreases during treatment and does not return to prediagnosis levels after treatment completion....
[...]
Journal Article•
2,029 citations
TL;DR: The results suggest that access to a supportive physical environment is necessary, but may be insufficient to increase recommended levels of physical activity in the community, and that greater emphasis be placed on creating streetscapes that enhance walking for recreation and transport.
1,310 citations
"An exercise oncology clinical pathw..." refers background in this paper
...Furthermore, motivation,(13) environmental constraints, and concerns about safety during cancer medical therapies are barriers that challenge exercise engagement.(14,15) In the case of exercise, it is widely recognized that 1 size does not fit all....
[...]
University of British Columbia1, Oregon Health & Science University2, Heidelberg University3, Utrecht University4, Northern Arizona University5, University of Alberta6, George Mason University7, Wingate University8, American Cancer Society9, University of California, San Francisco10, Penn State Cancer Institute11
TL;DR: Enough evidence was available to conclude that specific doses of aerobic, combined aerobic plus resistance training, and/or resistance training could improve common cancer-related health outcomes, including anxiety, depressive symptoms, fatigue, physical functioning, and health-related quality of life.
Abstract: 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
1,174 citations
"An exercise oncology clinical pathw..." refers background in this paper
...All individuals should be counseled on the recommended physical activity guidelines and encouraged to maintain levels of activity during cancer treatment.(56) When an oncology provider encourages exercise, patients are more likely to pursue the intervention....
[...]