Clinical Implementation of Exercise Guidelines for Cancer Patients

17 Pages·2017·0.54 MB·English

Journal of
Functional Morphology
and Kinesiology
ConceptPaper
Clinical Implementation of Exercise Guidelines for
Cancer Patients: Adaptation of ACSM’s Guidelines to
the Italian Model
LauraStefani1,*,GiorgioGalanti1andRiggsKlika2
1 SportsMedicineCenter,ClinicalandExperimentalDepartment,SchoolofSportsMedicine,
UniversityofFlorence,50100Florence,Italy;giorgio.galanti@unifi.it
2 DepartmentofSportsMedicine,PepperdineUniversity,Malibu,CA90263,USA;
[email protected]
* Correspondance:laura.stefani@unifi.it;Tel.:[phone];Fax:[phone]
AcademicEditor:GiuseppeMusumeci
Received:6November2016;Accepted:30December2016;Published:13January2017
Abstract: Thegoalofcancertreatmentistoarrestoreradicatethetumorwhileminimizingtheoften
toxiceffectsoftreatment. Whileoncologicdiagnosticsandtreatmentsareimprovingandsurvival
ratesareincreasing, itiscriticaltoprovideadditionalpatientmanagementthatappearstoaffect
long-termsurvival. Epidemiologicevidencesuggestspatientsdiagnosedwithcancertendtofair
betteraftertreatmentwhenfollowingacomprehensiverehabilitationprogramaimedatachievingan
idealbodyweightthroughdietaryandexerciseinterventionswhilealsoincreasingcardiorespiratory
fitness,strength,mobility,neuromuscularintegrityandpsycho-socialwellbeing. Additionally,itis
nowbeingtestedwhetherexerciseduringcancertreatmentandpossiblypriortothestartoftreatment
mayincreaseposttreatmentoutcomesbyalteringbodyweight,havingdirecteffectsontumorigenesis,
reducingoxidativestressandinflammation,andperhapsincreasingchemotherapydeliveryefficacy.
Thepurposeofthisreviewistooutlineanevidencebasedmodeltoevaluatecancerpatientsand
provideguidelinesforpost-cancertreatmentrehabilitationprograms. Additionally,strategiesaimed
atchanginglifestylehabitssuchassmokingandpoordietaryhabitswillbeaddressed.
Keywords: cancer; rehabilitation; physical activity; strength training; aerobic fitness; quality of
life;survivor
1. Introduction
Cancerisamongtheleadingcausesofmorbidityandmortalityworldwide,withapproximately
14millionnewcasesand8.2millioncancerrelateddeathsin2012andanincidencerateexpectedtorise
by70%overthenexttwodecades[1]. Itiswelldocumentedthattumorgenesisandcancertreatment
isassociatedwithadversephysicalandphysiologicalchangesleadingtometabolicandfunctional
modifications, inducing pathologies of the cardiac, pulmonary, neural, bone and skeletomuscular
systems[2]. Thesealterationseffectcardiorespiratorycapacity(fitness),strength,bodycomposition,
and physical function including immune system integrity, peripheral neuropathy, and quality of
life[3–8]. However,itisincreasinglyclearthatprescribingexerciseduringandpost-cancertreatment
maymitigatemanyoftheseadversechanges(Table1)bydecreasingtissueinflammationcontributing
totumorgenesis[9–14].
J.Funct.Morphol.Kinesiol.2017,2,4;doi:10.3390/jfmk2010004 www.mdpi.com/journal/jfmk
J.Funct.Morphol.Kinesiol.2017,2,4 2of17
Table 1. Late and long-term effects of cancer treatment where physical activity can have a
positiveimpact.
CancerTreatment PhysicalChanges PsychologicalandBehavioralChanges
↓ pulmonaryfunction ↓ decreasedexercise/physicalactivity
↓ cardiacfunction ↑ physicalsymptomsandpain
↓ musclemass ↑ depression
Surgery
↑ fatmass ↓ cognitivefunction
Radiation
↑ bodyweightorbodymassindex ↓ qualityoflife(multipledomains)
Chemotherapy
↓ decreasedmusclestrength/power
Immunotherapy
↑ inflammation
HormoneTherapy
↓ immunefunction
SteroidTherapy
↓ bonehealth
↑ traumaandscarring
↑ lymphedema
Given the high prevalence, incidence and the complexity of the management of the disease,
interest from Internal Medicine and specifically Sports Medicine professionals has increased
proportionally especially as it relates to prescribing physical activity to offset the adverse effects
oftreatment. Themodificationoflifestylefactorspost-cancertreatmenthassurfacedasanemerging
need. Currently in Italy, the Sports and Exercise Medicine specialization is dedicated to lifestyle
managementspecificallyaddressingchangingbehaviorpatternsinindividualswhowerepreviously
sedentary[9]. Therefore,thepurposeofthisconceptmanuscriptistoreviewclinicalissuesrelatedto
cancertreatmentandtooutlineamodelofexerciseprescriptionforcancerpatientsundertheItalian
healthcaremodel. Thissystemallowsforanintegratedapproachbetweensportsmedicinespecialists,
oncologists,physicaltherapists,nutritionists,mentalhealthprofessionalsandpersonaltrainers.
2. MedicalTreatmentConsiderationsandContraindications
Hereweprovideabriefreviewofmedicaltreatmentsforcancerincludingsurgery,chemotherapy,
radiotherapy and selected associated complications which include lymphedema, cardiotoxicity,
chemotherapy induced peripheral neuropathy, cancer-related fatigue and general metabolic
disturbances. While it is important to consider each of these factors in a comprehensive cancer
rehabilitationprogram,itisrelevanttonotethatcancersurvivorsareatelevatedriskofrecurrence,
developmentofsecondarycancers,cardiovasculardiseaseandprematuredeathsincetheincidence
andprevalenceofcancerishigherinsubjectsaged>55years[15]. Normalage-relatedchangesin
physicalfunctioninadditiontoasedentarylifestyleincreasetheriskofco-morbiditiesthatareoften
seeninthecancerpatient[16]. Therefore,thecorrectclinicalapproachforthecancerpatientshouldbe
rootedinthoroughclinicalpatientevaluationwhichultimatelywillbeusedtodeterminetheoptimal
time to begin a patient specific exercise/rehabilitation program. In the Italian model, the Sports
Medicineprofessionalshouldprescribeexerciseanddietaryguidelinesinordertoreducetheriskof
co-morbidities,clinicalcomplicationsandprematuremortality. Literaturesupportstheimportanceof
theexerciseprescriptionacrossthemanytypesofcancer,howeverthemajorityofdatainthisfieldhas
beenobtainedmainlyinbreastandcoloncancersurvivors[17,18].
2.1. Surgery
Surgery is considered a foundation of cancer treatment and includes removal of the entire
tumor/tumor bed, debulking and in some cases is used to ease cancer symptoms. Surgery is
associatedwithpain,limitedrangeofmotion,andpotentiallyotheracutecomplicationslikeinfection,
bleedingorthrombosis. Moreover,aftersurgicaltreatment,patientsoftenbecomemoresedentary
duetopostsurgicalcomplications. Reconstructivesurgerycreatesadditionalmedicalcomplications
(e.g.,abdominalorlatissimustram-flapreconstruction)thatshouldbeconsideredbytherehabilitation
specialist. Assurgicaltreatmentcanbeindicatedatanytimeduringthecancercontinuum,longterm
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managementofthecancerpatientshouldstartwithaninitialperiodofacuterehabilitationfollowed
byanextendedperiodofbodyreconditioningfollowinganysurgicalprocedure.
2.2. SurgicalComplications: Lymphedema
Secondary lymphedema as a result of axillary node dissection is a common complication in
subjects undergoing surgical treatment for breast cancer. Complications due to lymphedema are
importantbecausetheycontributetoself-reportedalterationsofbodyimage,decreasedarmfunction
andincreasetherisktosecondaryinfections. Arecentmeta-analysissuggestsurgicallymphedema
occursinapproximatelyoneoutoffivebreastcancersurvivorsandthatwomenwhohaveaxillarynode
dissectionvs. sentinelnodedissectionareatafourfoldincreasedriskofdevelopingthecondition[19].
In addition to axillary-lymph-node dissection, the greater number of lymph nodes dissected,
mastectomy(partialandradical),obesityandphysicalinactivityareassociatedwithincreasedriskof
developinglymphedema. Assuch,strategiestoincreasegeneralphysicalactivity,increasemovement
intheeffected-sidearm,andimprovebodycompositionhavebeenconsidered. Recentstudiessuggest
thatresistanceexerciseinwomenwithbreastcancerisbothsafe(whenmonitoredappropriately),may
decreasetheriskoflymphedemadevelopmentandclearlydecreasesthesignsandsymptomsofthe
condition[19,20]. InarecentlypublishedCochranereview,theeffectsofmanuallymphaticdrainage
independentlyand/orcombinedwithexercisetherapyhaveprovidedinconclusiveresultshowever,
itwasreportedthatshouldermobilitysuchaslateralmovementsandforwardflexionwerebetter
whenstartingshoulderexercisesearlierratherthanlater(aftersurgery)andthatprogressiveresistance
exercisetherapydoesnotincreasetheriskofdevelopinglymphedema[21]. Schmitzreportedin2010,
thatresistancetraininginbreastcancerpatientsnotonlywasindicatedinrehabilitationprograms,
butalsoreportedlesslymphedemainhercohort[22]. Itthereforeseemsreasonable,thatincreased
movementinareassusceptibletolymphedemamayactuallyimproveclinicaloutcomesbyincreasing
musclepumpandthereforeeffectivelyremovinglymphfromtheextremities. Iflymphedemaisa
concern,pre-andpost-exercisemeasuresoflimbcircumferenceshouldbetakenandreported. Serious
lymphedema should be immediately referred to the oncology team for further evaluation. Use of
compressiongarmentsisencouragedifriskofswellingishigh. Guidelinesforlymphedemamitigation
maybefoundatwww.lymphedema.orgmedicaladvisorycommitteefortheNationalLymphedema
Network[20].
Another complication of surgery (particularly partial mastectomy, radical mastectomy, and
reconstructivesurgeriesforbreastcancer)includesscarringandrestrictedmobilityintheeffectedside
ofthebody.Thisissimilartoandhighlyrelatedtoradiotherapyscarring(seesectiononradiation).Asa
resultofsurgicaltraumaand/orradiotherapyandconservativephysicaltherapy,itisnotuncommon
forbreastcancersurvivorstoexperienceadhesivecapsulitisor“frozenshouldersyndrome”asaresult
ofcompensatoryprotectivemechanismspost-surgery[23]. Currentstrategiesaimedatreducingthe
riskof“frozenshouldersyndrome”includeprogressivemobilityexercises,stretchingandaprogressive
resistancetrainingprogram(seesectiononresistancetrainingforcancerpatients).
2.3. Radiotherapy(RT)InducedPathology
Radiotherapygenerallyimprovespatientsurvivalamongdifferingcancerdiagnoses,however,
itcaninducecardiomyopathy,mainlypericardialinvolvementwhenusedincertaincancerssuchas,
lung,breast,thyroidandHodgkinlymphoma. Thiscardiomyopathyistermedradiationinducedheart
disease(RIHD)andischaracterizedbyseveralabnormalitiesinthecoronaryvessels,pericardium,
valvesandmayinduceconductiondefects[24]. Histopathologicalstudieshavedemonstratedthat
radiationinducesfibrosisofthemyocardiumwhichultimatelyleadstoadecreaseinelasticityand
distensibility of the muscle, and therefore leads to reduced diastolic function which progresses
to significantly smaller ejection fractions [25,26]. This mechanism can increase the incidence of
arrhythmiasandpotentiallydepresscardiacfunctionforextendedtimeperiods. Additionally,there
appearstobeanaccelerationoftheatheroscleroticprocessduetosub-endothelialfibrosis,fibrosisof
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lymphaticchannels,microvasculardamage,allwhichcanleadtoaprogressivedeteriorationofthe
conductingtractsornodesinthemyocardialtissue. Thesesymptomsareoftenspecificforthesiteof
involvementandthereforeexclusionofdiseaseslikehypertension,coronaryarterydisease(CAD)or
othersismandatoryduringtheclinicalassessment.
Survivors of breast cancer and Hodgkin Disease (HD) are at the greatest risk of RIHD.
The mechanisms by which these abnormalities are caused in the heart are described in detail by
Madanetal.[26],andarelinkedtoincreasedinflammation,mediationoftumornecrosisfactor(TNF),
interleukins(IL), IL-1, 6, and 8whichincrease furthercoronary arteryneutrophilinfiltration. Itis
importanttonotethatRIHDgenerallyoccursafteralatentperiodof10–15yearsandisofspecial
concernforyoungercancersurvivors. BecauseofthelatenteffectsofRIHD,itisessentialthatlong
termfollow-upandpreventiveclinicalmanagementofhighriskpatientsbeconsidered.
2.4. Chemotherapy(CT)InducedPathology
CT is used to cure, control, or in palliation and is recognized as a main reason for increased
survivalratesofcancerpatients.CTincludescytotoxicagents,hormonalblockers,andreceptorspecific
targetedtherapy. Dependingonthedrugandadministrationcycle, thesedrugseffectnormalcell
reproductionandoftenleadtomyelosuppression,immunosuppression,mucositis,andalopeciaand
insomecasestheadverseeffectmaybefatal[8]. Intherehabilitationsetting,detaileddocumentation
includingcompletebloodcountsoftheseconditionsisconsideredessentialinthedevelopmentofthe
exerciseprescription.
CT induced cardiotoxicity can be a subtle event in the cancer continuum as adverse effects
are often asymptomatic for prolonged periods of time. Accordingly, CT induced pathology is
diagnosed as an expression of left ventricular dysfunction and is defined as a ≥5% reduction in
leftventricularejectionfraction(EF)insymptomaticpatientsora≥10%reductioninasymptomatic
patientswhenmeasuredfrombaselinewithanupperlimitof<55%. Astheincidenceofcardiotoxicity
ispotentiallyhighincancerpatients,itiscriticalthatmyocardialfunctionbeassessedregularlyin
theclinicalcardiology/sportsmedicinepracticeandthatthatinformationisconveyedtotheentire
rehabilitationteam.
InadditiontodecreasedEF,adverseeffectsofCTincludeheartfailure,thromboembolism,severe
hypertensionandlethalarrhythmiaswhichmayinterruptcancertreatmentanddecreasesinapatient’s
quality of life. Among the principal CT drugs, doxorubicin, tamoxifene and trastuzumab are the
mostcommoncauseofheartfailure. TrastuzumabisaHer2/neureceptorinhibitorapprovedbythe
UnitedStatesFederalDrugAdministrationbuthasbeenshowntoinducemyocardialdysfunctionin
7%–18%ofcancerpatients[27]. OverexpressionofHer2/neureceptorisassociatedwithprogression
of malignancy in breast cancer [27]. The abnormal changes in heart’s function can escape the
traditionaldiagnosisbasedonejectionfractions(i.e.,volumedependentparameters),while“strain”
andparticularlyGlobalLongitudinalStrain(GLS),ameasureofcontractilitybydeformation,andcan
behelpfulinthisdetectionintheearlyphase[28]. Itistherefore,essentialthatcardiacfunctionbe
evaluatedassoonasisfeasibleafterpotentiallycardiotoxictreatmenthasendedandpriortothestart
oftherehabilitationprogram.
CTinducedcardiotoxicitypreventionisoneofthemostimportantaspectsofcardio-oncology.
Consideringthatcardiacdamagemaylimitoptimalanticancertreatmentandthatseveralpathological
myocardialchangescanbeirreversible,anappropriatemanagementshouldincludebetterdetectionof
thosepatientsatrisk,thedevelopmentofpreventivestrategiesandtheearlytreatmentofcardiotoxicity
when it does appear [29]. Despite the fact that there are some cardioprotective drugs (i.e., statins,
beta-blockers,nitrates;angiotensionconvertingenzyme(ACE)inhibitors)inordertoreduceoxidative
stress(reactiveoxygenspecies),improvelipidprofiles,decreasebloodpressureandimprovevascular
blood flow and potentially decrease incidence of mortality and morbidity, it has been shown that
physicalexercisecanbeconsideredabetter“polypill”foritsmultipleeffectsinprotectingtheheart
withlessadversesideeffects[30]. Themechanismofactionofexerciseasapowerfultherapeuticin
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reducing cardiovascular disease is linked to improved endothelial function via decreased fibrosis,
increased vasodilatation effect better heart rate variability (via improved neural sensitivity in the
heart),lowerlevelofreactiveoxygenspecies(ROS’s)andimprovedlipid-clotformingprofiles.
2.5. CancerRelatedFatigue(CRF)
CRFisoneofthemostcommonsymptomsofcancertreatmentsandhasbeenreportedtoeffect
up to 80%–90% of cancer patients [6]. CRF is characterized by tiredness, weakness, and lack of
energyasaresultofacomplexsequenceofeventseffectingmetabolism,immunefunctionandmental
wellbeing. CRF fatigue is differentiated by its general fatigue by its severity and the fact that it is
oftennotalleviatedbyrestorsleep[6,31]. Asaresult, cancerpatientswithCRFalsopresentwith
depression and lower quality of life (QoL) measures. The early symptoms may be undiagnosed
or inadequately interpreted. Potential mechanism in the development of CRF may be related to
alteredmetabolismduetodecreaseperipheralcirculation,alteredsubstrateutilizationandincreased
inflammation. Additionally,tumor-relatedfactorsincludingelectrolyteabnormalities,dehydration,
cachexia,thrombosis/pulmonaryembolism,renalfailure,liverfailure,hypoxia,adrenalinsufficiency,
neurologicaldeficithavebeensuggestedascauses[6].
CRF has deleterious effects on many aspects of a patient quality of life, and for this reason a
screening for fatigue at their initial clinical visit and then regularly during and after their cancer
treatmentisimportant. AmongthemostcommonandimportantfactorsrelatedtoCRFandwhere
potential pharmacological interventions are aimed include adjusting CT dosage and/or treating
anemia. Forlongtermsupport,regularphysicalexercisehasbeenshowntodecreasebothdepression
and fatigue [31]. Several clinical studies and meta-analyses have shown the benefits of increased
physicalactivity/exerciseonCRF,physical/emotionalfunctioning,insomniaandoverallqualityof
life[6,13,32].
2.6. CancerInducedPeripheralNeuropathy(CIPN)
CIPN is a common toxicity associated with cancer treatment that is progressive, often
debilitatingandoccasionallyirreversibleandhasbeenshowntoaffect30%–40%ofcancerpatients
undergoingchemotherapy. CIPNisassociatedwiththalidomide,vincristine,vinblastine,paclitaxeland
docetaxel,proteaseinhibitorsplatinumbaseddrugsincludingcisplatin,oxaliplatinandcarboplatin.
The condition is characterized by pain, tingling, numbness and temperature sensitivity. Axonal
degenerationbyanyoftheseagentsleadstoakinesia,dyskinesia,allodynia,peripheralskeletalmuscle
weaknessandindirectlyeffectsbalanceandincreasestheriskoffalling. SuspectedCIPNshouldbe
evaluatedclinicallyandsitespecificrehabilitationshouldbeincorporatedposttreatment. Further
drugtherapyisoftenprescribedforpainreliefandshouldbeconsideredaspartoftheprogram.
CIPNriskfactors,fallriskandprevalenceinlong-timecancersurvivorshasbeenwellstudied
andmainlyinbreastcancerpatients[33,34]. Thepositiveeffectofexerciseappearstoberelatedto
reducing pain and improving physical function [14]. Mechanistically, there is emerging evidence
tosuggestthatexerciseandperipheralmusclestimulationmaydecreasesaxonaldegenerationand
maintainperipheralneuronalfunction(presumablyviabetterbloodflowintheregion)[35]. Therefore,
strategies for increasing overall physical activity and limb/region specific rehabilitation in cancer
patientsreportingCIPNshouldbeincorporatedinordertoincreasestrength,improvebalance,and
qualityoflifepresumablybydecreasingtheseverityofpain[14].
2.7. MetabolicDisturbances
Alteredwholebodymetabolismasaresulttumormetabolismmaynecessitateincreasedcaloric
intake to offset cachexia (muscle wasting). Additionally, mitochondrial destruction and loss of
peripheralcapillarydensity,mayshiftsubstrateutilizationasseenbyincreasedwholebodyglucose
production, increase glutamine, increased glycolysis and changes in the use of metabolic enzyme
isoformsandincreasedsecretionoflactate[36]. Asaresultofperipheralanatomicalchangesand/or
J.Funct.Morphol.Kinesiol.2017,2,4 6of17
changeinmetabolicsubstratesources,cardiorespiratoryfitness(CRF)/aerobiccapacitymaybeaffected.
OtherfactorsaffectingCRFarerelatedtophysicalinactivityassociatedwithtreatment,cancerrelated
fatigueanddepression. Asaresult,theabilitytotransportandeffectivelyuseoxygenintheskeletal
muscleiscompromisedtosuchanextentthatsubstrateutilizationmaybealtered(ashiftfromaerobic
respirationtoanaerobicglycolysis)[3]. Whilethisareaofresearchisincomplete,itisimportantto
considerthatmetabolicdisturbancemayaffectexerciseabilitiesofcancerpatients.
3. ContraindicationsforParticipatinginExerciseProgramsamongCancerPatients
Despitethefactthatphysicalactivityissuitableformostcancersurvivorsinstablecondition,a
regularmedicalcheckupisimportantinorderforearlydetectionofanypotentialacutecomplications
contraindicatingphysicalactivity. IntheItalianhealthcaremodel,standardofcareisafollowupwith
asportsmedicineprofessionaltoadministerandreviewcardiovascularperformanceevaluationswith
electrocardiographywhichinclude6-minwalkingtests(6MWT),exercise/stresstestsand,ifnecessary,
stressechocardiography. Thedifferentassessmentsaredependentontheclinicalconditionsofthe
presentingcancerpatients. IntheItalianmodel,theSportsMedicineprofessionalhastheexpertiseand
trainingtoevaluatetheseconditionsandthendirecttherehabilitationandexerciseprescriptionplan.
It is important to monitor hematologic abnormalities (e.g., low platelets, hematocrit and
hemoglobin levels, and neutrophil counts), musculoskeletal disorders (e.g., recent bone, back
or neck pain; unusual muscular weakness; extreme fatigue; severe cachexia), gastrointestinal
disorders(e.g.,severenausea,vomitinganddiarrhea,dehydration,poornutrition),cardiovascular
disorders (e.g., chest pain, elevated resting heart rates, elevated blood pressure (both systolic
and diastolic), irregular heartbeats, lymphedema), pulmonary disorders (e.g., severe difficulty
breathing, coughing/wheezing), and neurological disorders (e.g., decline in cognitive status,
dizziness/lightheadedness, disorientation, blurred vision, increased postural instability) [37].
A comprehensive list of contraindications to exercise testing and training is included in Table 2.
One specific contraindication not listed below is associated with radiotherapy treatment whereby
pool swimming is contraindicated because of the increased risk of potential infections and burn
siteirritation.
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Table2.Contraindicationsandprecautionstotheexerciseprescriptionforcancer.
ClinicalCancerComplicationsand
ContraindicationstoExerciseTestingandTraining PrecautionsRequiringModificationand/orPhysicianApproval
AcuteConditions
Noexerciseondaysofintravenouschemotherapy Cautionifontreatmentsthataffectthelungand/orheart:recommendmedically
(recommendationchanging) supervisedexercisetestingandtraining
FactorsRelatedtoCancerTreatment
Noexercisebeforeblooddraw Mouthsores/ulcerations:avoidmouthpieceformaximaltesting:usefacemask
Severetissuereactiontoradiationtherapy Lymphedema:wearappropriatecompressiongarments
Platelets>50,000–150,000:avoidtestsorexercise(contactsports)thatincreaserisk
PlateletCount<50,000
ofbleeding
Hematologic Hemoglobinlevel<10.0g/dL Whitebloodcells>3000–4000:ensurepropersterilizationofequipment
AbsoluteNeutrophilCount<0.5×109/L Hemoglobin>10g/dL(11.5–13.5g/dL):cautionwithmaximaltests
Avoidactivitiesthatmayincreasetheriskofbacterialinfection(swimming)
Extremefatigue/muscleweakness Anypainorcramping:investigate
Bone,backorneckpain Osteopenia:avoidhigh-impactexerciseifriskoffracture
Musculoskeletal
Severecachexia(lossof>35%premorbidweight) Lossofmusclemasslimitsexercisetomildintensity
Karnofskyperformancestatusscore<60%;Poor
Cachexia:multidisciplinaryapproachtoexercise
functionalstatus:avoidexercisetesting
Mayindicatesystemicinfectionandshouldbeinvestigated.Avoidhigh
Acuteinfections
intensityexercise
Systemic
Febrilillness:fever>100F Avoidexerciseuntilasymptomaticfor>48h
GeneralMalaise
Compromisedfluidand/orfoodintake:recommendmultidisciplinary
SevereNausea
approach/consultationwithnutritionist
Gastrointestinal Dehydration Ensureadequatenutritionwithelectrolytedrinksandwater(avoidhyponatremia)
Vomitingordiarrheawithin24–36h Avoidexercise
Poornutrition:inadequatefluidand/orintake Avoidexercise
Chestpain Exerciseiscontraindicated(refertophysician)
RestingHR>100bpmor<50bpm Caution:recommendmedicallysupervisedexercisetestingandtraining
RestingSBP>145mmHgand/orDBP>95mmHg Cautionwithexercise
Cardiovascular
RestingSBP<85mmHg Cautionwithexercise
IrregularHR Exerciseiscontraindicated(refertophysician)
Swellingofankles Lymphedema:wearappropriatecompressiongarments
Dyspnea Mildtomoderatedyspnea:avoidmaximaltests
Pulmonary Cough,wheezing Avoidactivitiesthatrequiresignificantoxygentransport(highintensityX)
Chestpainincreasedbydeepbreath Avoidexercise
Ataxia/Dizziness/peripheralSensoryNeuropathy Avoidactivitiesthatrequiresignificantbalanceandcoordination(treadmill)
Significantdeclineincognitiveperformance Ensurepatientisabletounderstandandfollowinstructions
Neurologic
Disorientation Usewellsupportedpositionsforexercise
Blurredvision Avoidactivitiesthatrequiresignificantbalanceandcoordination
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3.1. MedicalAssessment
TheItalianmodelforcancerrehabilitationforcompletelifestylerestorationisamultidisciplinary
model incorporating the Sports Medicine physician first that interacts with oncology, eventually
cardiology, internal medicine or primary care, and rehabilitation medicine, and is supported by
ancillaryhealthcareprofessionalsincludingphysicaltherapists,occupationaltherapists,nutritionists
andexercisetrainers.
Entryofapatientsforan“exerciseismedicineprogram”isinitiatedbyoncologists,whilethe
evaluationandtheassessmentoftheprogramneedsaspecificcompetenceinSportsMedicinewhere
the culture of exercise and an understanding of the acute and chronic impact of sports training
in patients is well known. Following referral from the oncology team, regular follow- up by the
SportsMedicinephysicianismandatoryespeciallyforthepotentiallongtermdamageasaresultof
chemo-andradio-therapy.
Postcancertreatment,standardofcareforthecancerpatientincludesstandardechocardiography
andmorerecentlybytheuseofsophisticatedsoftwarepackagessuchasspeckletrackingwhichis
usedtoinvestigateheartdeformationparametersinordertoclassifytheextentofcardiactoxicity.
Additionalstressechocardiographymaybenecessaryinordertoevaluatemyocardialresponseto
exerciseandpossiblyaidintheexerciseprescriptionforthepatients. Thesesymptomlimitedgraded
exercisetestsincludesbloodpressuremonitoringandterminationat85%age-predictedmaximalheart
rate. Basedonresultsofthestressechocardiogram,intensityoftheexercisecanbeestablishedatlower
heartratevaluesespeciallyiftheratingofperceivedexertionduringtestingisnotproportionaltothe
actualworkoutput. ShouldECG(Electrocardiogram)orwallabnormalitiesbefoundtotheextent
thatexerciseiscontraindicated,thepatientisevaluatedbytheSportsMedicineteam(becauseoftheir
clinicalunderstandingofthecardiac-exerciseconnection)andre-scheduledforfollowup.
3.2. OtherAssessments
Body composition should be assessed to estimate percentage of fat and used to calculate fat
freeandfatmass. Inthehospitalsettingdual-X-rayabsorptiometryisconsideredagoldstandard
whilebodycompositioncanbeestimatedintheout-patientclinicalsettingthroughskinfoldmeasures,
bio-electricalimpedance, near-infra-redspectrometry, orplethysmography. Itisbeyondthescope
ofthisreviewtoreviewthestrengthandweaknessesofeachofthesebodycompositiontests. Itis
however,animportantmeasureasreachinganidealbodysizeandcompositioniscriticalforlong
termsurvival[38].
Strengthevaluation:Intheclinicalsetting,strengthisoftenassessedusinghandgripdynamometry.
StandardshavebeenpublishedbytheAmericanCollegeofSportsMedicine[39].
Flexibilityevaluation: Intheclinicalsettingflexibilityisoftenassessedusingthesitandreachtest.
StandardshavebeenpublishedbytheAmericanCollegeofSportsMedicine[39].
It should be noted that post-surgical treatment, physical therapists may determine strength,
flexibilityandrangeofmotionusingpracticespecificassessmentsandnormativedatawhicharebetter
representativeoftheirconditioncomparedtonormativedatacompiledonhealthyindividuals.
QualityofLifeevauation: Intheclinicalsetting,thereareanumberofvalidatedqualityoflife
assessmenttools. The36-itemshortformhealthsurvey(SF-36)andthefunctionalassessmentofcancer
therapy-general(FACT-G)arecommonlyused[40,41].
3.3. ExerciseGuidelines
Exerciseguidelinesforcancersurvivorshavebeenpreviouslypublished[13]andarethebasisof
ourrecommendationspost-cancertreatment. Theefficacyandsafetyofexercisetestingandexercise
trainingpost-cancertreatmenthasbeenpreviouslypublished[42]andtestingandtrainingappear
relativelysafe. InEuropeandalsoinItaly, wherethecharacteristicsofthegeneralpopulationare
different from the American counterparts, the management of cancer survivors is relatively new.
J.Funct.Morphol.Kinesiol.2017,2,4 9of17
TheapproachpresentedherehasnotbeenvalidatedbutitiscloselyrelatedtotheACSMguidelines.
Recentlyexerciseduringcancertreatmenthasbeensuggestedtoslowtheoverallrateofphysiologic
declineandmaintainbetterqualityoflife[43]. Currently,therearenovalidatedguidelinesforexercise
duringcancertreatmentandpractitionersareencouragedtoproceedcautiouslyuntilfurtherdatahas
beenscrutinized.
Thereisclearrelationshipbetweencardiorespiratoryfitness(CRF)andmortalitywhichsuggests
thatthosewiththehighestCRFhaveasignificantlylowerriskofprematuredeathtothecanceritself
orotherage-relatedco-morbidities[44]. Therefore,ifthehealthofthegivenpatientisrelativelygood,
theyshouldbeencouragedtodomorethanthecurrentexerciseminimums. Giventheimportanceof
theoxygencascadeandtherelationshipofCRFandcancerrelateddeath,oneprimarygoalofcancer
rehabilitationistoarrestthedeclineinaerobicfitnessduringtreatmentandthenrestoreaerobicfitness
topre-diagnosislevelswithanultimategoalofimprovingaerobiccapacityabovepre-diagnosislevels.
Cancer survivors of all cancer-types and at all stages of cancer have been shown to increase
aerobiccapacitywhengiventheappropriateoverload[13]. Fromascientificperspective,theaimis
toachieve500–1000MetabolicEquivalentofTask(MET)minutesofactivityperweekwhereaMET
isthemetabolicequivalentofenergyuse. Forexample,1METisconsideredtheenergyusedwhile
restingandisequivalenttoanoxygenconsumptionof~3.5mL·O ·kg−1·min−1. AMETperminuteis
2
definedasthelevelofintensityxtime(minute)doingtheactivity. Forexample: TheMET/minutesfor
walkingat4km·h−1(METlevel=2.9)×30min=87MET/minutes[45].
In order to achieve the 500–1000 MET/minute per week the following guidelines have been
validated. Cancerpatientsshouldsetasagoalofatleast150min(2.5h)aweekofmoderate-intensity
or75min(1.25h)aweekofvigorous-intensityaerobicphysicalactivity,oranequivalentcombination
ofmoderate-andvigorous-intensityaerobicactivity. Aerobicactivityshouldbeperformedinepisodes
ofatleast10min,andpreferably,itshouldbespreadthroughouttheweek. Whenolderadultscannot
do150minofmoderate-intensityaerobicactivityaweekbecauseofchronicconditions,theyshouldbe
asphysicallyactiveastheirabilitiesandconditionsallow. Foradditionalandmoreextensivehealth
benefits, cancer patients (if able) should increase their aerobic physical activity to 300 min (5 h) a
weekofmoderate-intensity,or150minaweekofvigorous-intensityaerobicphysicalactivity,oran
equivalentcombinationofmoderate-andvigorous-intensityactivity. Additionalhealthbenefitsare
gainedbyengaginginphysicalactivitybeyondthisamount[45].
3.4. ExerciseIntensity
Exerciseintensitylevelsshouldbeestablishedbasedonclinicalevaluationtoensureoverallpatient
safetywhichshouldincludephysicianassessmentviagradedexercisetestingwithelectrocardiography
orechocardiography. Heartrateiscurrentlythepreferredmethodtoestablishexerciseintensitywhile
manyresearchershavehadsuccessusingtheCR10orBorgratingofperceivedexertionscale(1–10).
The current exercise guidelines for cancer patients suggest an intensity level of moderate-to-
vigorous, which is defined as 40%–60% of maximal oxygen uptake reserve (VO reserve) or heart
2
ratereserve(HRR)[13]. Wewillonlyconsiderheartratereserveforthisdiscussion. However,itis
importanttoemphasizethatinItaly,thecurrentmodelincludesboththecalculatedHRintensitiesand
CR10scale.
HRRisdeterminedastheheartratemaximum(HR )−heartraterest(HR ). HR canbe
max rest max
estimatedfromtheequation208bpm−70%×ageorideallymeasuredinaclinicalsetting[46]. Many
timeswhencompletingasymptomlimitedcardiopulmonaryexercisetest,HR isnotachievedand
max
thereforepeakheartrate(HR )isusedasanupperlimitforHRRcalculations. Itshouldbenoted
peak
thatestablishingexerciseintensitybasedonHR mayresultinunderestimateofexerciseintensity
peak
needed for improvements in fitness and the clinician will have to use best judgement to establish
anupperHRlimitforeachcancerpatient. Ithasalsobeenreportedinbreastcancersurvivorsthat
prescribing exercise intensity based on HRR may result in higher exercise intensity than intended
andthereforeshouldbeusedconservatively[47]. Vigorousexerciseisdefinedas≥60%HRRorVO
2
J.Funct.Morphol.Kinesiol.2017,2,4 10of17
reserveoranditissuggestedforsafetyconcernsnottoexceed85%ofHRR.InthecurrentItalian
model,maximalexercisetestingisterminatedat85%ofanage-predictedHR . HRRreserveand
max
exerciseintensitiesaresubsequentlydeterminedfromtheseresults.
3.5. PracticalApplication
Attheinitiationofanexerciseprogramforacancerpatientwhohasbeenpreviouslysedentary,
itmaybenecessarytobeginwithlightactivityandthenproceedtomoderate-to-vigorousexercise.
In general, light activity is defined as 1.1 up to 3.0 MET, Moderate activity is defined as 3.0 up to
6.0METandVigorousactivityisdefinedasmorethan6.0MET.(Table3).
Table3. IntensitytheaerobicexercisebasedonMETlevel,HeartRateReserve,RatingofPerceived
Exertion(RPE)withexamples.
Intensityof HeartRate Ratingof
METLevel ExerciseExamples
Exercise Reserve(HRR) PerceivedExertion
Standing,lightwalking,washingdishes,
Light 1.1–3.0 35%–50% 1–3
doinglaundry,cooking,lightcalisthenics
Walkingatamoderatepace,bicycling
8–14.5kph,wateraerobics,weight
Moderate 3.0–6.0 50%–70% 4–6 training,dancing,recreationalswimming,
gardeningandyardwork,moderate
homerepairorhousework
Walkingbriskly(>8kph),Jogging,
running,bicycling,backpacking,aerobic
dancing,vigorouscalisthenics,circuit
Vigorous 6.0+ 70%–85%* 7–8 weighttraining,tennis,mostcompetitive
sports,lapswimmingforfitness,heavy
gardeningandhousework,occupational
workwithheavyloads
*:Itissuggestedforcancerpatientsnottoexceed85%HHR;MET=MetabolicEquivalent;MET-minutes=MET
level×exercisedurationinminutes;Goal:500–1000MET-minutesperweek.
Fromarelativeintensitylevel, useoftheCR10orModifiedBorgscaleworkswell. Moderate
intensityactivityisalevelofeffortof6orbelowona1–10scalewhilevigorousintensityisa7–8on
the1–10scale.
Currently,effectiveaerobicconditioningprogramsappeartoincorporatesometypelowlevel
activityfollowedbyintermittenthighintensityexerciseinsignificantlyshorterdurations.Theseaerobic
trainingsessionsaretypicallyprescribedonalternatingdaysthroughouttheweek. Thisalternating
levelofhighintensity/lowintensityallowsforsignificantoverloadandstimulusforadaptationwhile
provingverysafeandeffective[48–50]. Notethatintheinitialphaseofconditioningatlowintensity
levels,itisnotnecessarytosupervisetheexercisesessionsbuthigherintensityexercisesessionsmay
needsupervisionbyahealthprofessional.
3.5.1. Modality
Walkingistypicallythepreferredmodalityofaerobicactivitybutanyandallmodalitiesshould
beconsideredforthecancerpatientwiththoughtgiventosurgicallimitations,radiationcomplications,
andperhapsanatomiclimitations(i.e.,cyclingforprostatepatients).
3.5.2. Anaerobic-ResistanceTraining
Cancertreatmentsaffectbonemineraldensity,musclemassintegrityandpossibleneuromuscular
function. Itisgenerallyagreeduponthatsometypeofresistancetrainingprogrambeprescribedfor
thecancerpopulation. Theindependenteffectsofstrengthtrainingincancersurvivorsaregenerally
suchthatstrengthandtoalesserdegreefunctionalitymaybeincreased. Ingeneral,maximalstrength
gainsincancerpatientshavebeenonaverage20%–50%[5]. Itis,therefore,recommendedthatadult