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Supporting the use of exercise during cancer: assessing, advising, and its referral by healthcare professionals

Exercise during cancer can be a tool for treatment, however, there remain barriers and to implementing exercise as a source of treatment into the healthcare system.

Exercise is medicine. It is commonly known that exercise is beneficial for those with cardiovascular diseases and also for healthy individuals. For cancer patients, the treatment options including chemotherapy, radiation, and surgical resection of tumor sites can have a weakening effect on the body in addition to psychological states of the patient.

In a recent multi-analysis published by the Cancer Journal for Clinicians, the introduction of exercise into the treatment plan for cancer patients was reviewed. Based on previous reviews and strong evidence, exercise has the potential to prevent a minimum of seven types of cancer; Colon, Breast, Endometrial, Kidney, Bladder, Esophageal (adenocarcinoma) and stomach cancers. Additionally, exercise has the ability to alter cancer-related health outcomes such as fatigue, depression, physical function, anxiety, and improve quality of life. It is suggested that 30 minutes of aerobic activity, three times a week, and resistance exercise twice a week can alter cancer-related outcomes. Despite this, multiple studies of cancer survivors have noted that 80% of patients are interested in receiving advice from clinicians regarding the use of exercise during treatment and post-cancer.

From the perspective of clinicians, recommending exercise programs also has its barriers. These include uncertainty regarding the safety and suitability of exercise for a particular patient, the lack of awareness of the available programs specific for cancer patients, and also that exercise programming is not within the scope of practice for clinicians. It is agreed between both patients and clinicians that exercise is beneficial as a tool in treatment, but the issue regarding exercise regime, safety for patients, monitoring and support during exercise creates this dilemma between both parties.

As such, there are practices that clinicians can now use to fix this issue, which includes assessing, advising and referring patients for exercise programs. This has been supported by the American College of Sports Medicine (ACSM) and is known as the Exercise is Medicine (EIM)  approach. The first step, assessment of physical activity, can be used as a vital sign, like blood pressure, as it gauges the current level of activity of the patient and also suggests to the patient that exercise is important to their recovery. The second step is to advise patients to increase their physical activity to the recommended activity levels, and if not met, it can lead to referrals; the third step. This transition allows the clinician to utilize the patients’ medical information, status of activity, and health barriers to asses the patient in regards to which type of exercise program may be suitable for the best course of care. As the clinician has the most current information on the state of the patient, they can determine if they are eligible to exercise with or without health professional supervision.

The options available to patients at this point in their use of the EIM approach is either Health Care Professional (HCP) supervised exercise, community programs, or by self-directed exercising. In an ideal model, hiring fitness instructors into the hospital setting would be preferred, but it has its implications in regards to the infrastructure of hiring trainers into the healthcare system and working with oncology physicians and nurses. Along with this, monitoring health status, the triage of the patient and the professional in charge of care during exercise programs is difficult and not yet in place in many healthcare systems, except in Canada and the Netherlands. Nevertheless, clinicians should not wait to refer patients until this infrastructure has changed. In the three options available to patients.

With HCP- supervised exercise programs, they typically occur within rehabilitation units, exercise facilities within the hospital, or primary care settings and palliative care units. The HCP’s include psychiatrists, physical therapists, clinical exercise physiologists, nurses, and/or occupational therapists. These individuals will have expertise in the therapeutic use of exercise and will focus programs on the improvement of physical fitness, physical function for patients along the cancer continuum and survivors. Along with this, the programs typically offered seek to minimize treatment side effects and functional decline, while post-treatment programs focus on optimizing physical functioning to allow activities of daily living and transition to community or self-directed programs. As such, patients will have continuous supervision during their exercise regimes, which would not be found in the other two options: community and self-directed programs.

Most community programs are held within community centers and recreational gyms that may have training programs allowing exercise trainers to learn training strategies and procedures for cancer patients. These courses include ACSM/ACS Certified Cancer Exercise Trainer and CanRehab cancer exercise specialist courses. Special programs such as the UK-based MoveMore and LIVESTRONG at the YMCA in the United States provides trainers the ability to focus their training for cancer patients. Overall, this allows patients to engage in the community and approach exercise regimes based on their own physical and psychological assessment, along with providing a cheaper cost to programs than HCP-supervised programs. Both options are far better than self-directed programs, especially when the symptoms and limitations on the patient are evident in their cancer progression.

As these options are available to cancer patients and survivors, the implementation of making exercise assessments, advising patients on making alterations to their levels of physical activity, and referring patients to exercise programs narrows down to the responsibility of oncology clinicians. As these clinicians have much work to make exercise a standard practice of treatment, along with identifying and treating patients with chemotherapy, radiation and tumor resections, there must also be support. These include changes in infrastructure and public awareness from policy makers, researchers, clinical educators, and healthcare providers.

The implementation issues noted above do make this transition difficult to include into healthcare systems worldwide, but there are options available to cancer patients and survivors today that can aid in their physical and psychological status and make exercise into medicine.

Written by P. Sukumar


  1. Schmitz, KH., et al. (2019). Cancer Journal for Clinicians. Exercise is Medicine in Oncology: Engaging Clinicians to Help Patients Move Through Cancer.
  2. Bohn, K. (2019) Eurekalert!. Exercise can now be prescribed like medicine for people with and beyond cancer.

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