Epidemiological studies have consistently shown that higher levels of physical activity significantly lower the risk of many cancers, cancer recurrence, and disease-specific and all-cause mortality (1,2). In addition, clinical trials published since 1983 (3) have demonstrated that supervised exercise training (i.e., moderate-to-vigorous aerobic and/or resistance training for >8 wk), prescribed during and/or after the completion of cancer treatments, is safe and can counteract treatment-related side effects (e.g., chronic fatigue), enhance health-related quality of life (HRQoL), and elicit many other physiological, functional, and psychological benefits. The data have been summarized in robust systematic reviews across many cancers, including those with advanced disease (4), and exercise guidelines have been published by Exercise and Sports Science Australia (5) and the American College of Sports Medicine (ACSM) (6).
In 2018, the Clinical Oncology Society of Australia (COSA) published a landmark position statement calling 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” (7). The statement calls for all members of the multidisciplinary team (e.g., oncologists, nurses, etc.) to promote exercise and that “best practice cancer care include referral to an accredited exercise physiologist (AEP) or physiotherapist with experience in cancer care (7).” The COSA statement (7) represents a major milestone as the first endorsement of exercise as an adjunct cancer therapy. However, efforts to implement this directive across Australia in the years ahead will come with many practical challenges.
Clearly defined, integrated and patient-centered models of care will be required to deliver exercise services to a growing number of cancer patients; otherwise, such services will remain peripheral to standard care and underutilized. We suggest that for the successful integration of exercise therapy to occur, exercise professionals and their services will have to become a respected, visible, and promoted part of the cancer treatment center itself (i.e., “part of the woodwork”). To this end, one of the foremost challenges is to conceptualize the potential role of an exercise professional employed within this setting, including how their services could be implemented to enhance patient outcomes across the cancer continuum in a broad range of cancers. However, we are aware of no report in the literature documenting the role or experiences of an exercise professional working within a cancer center, or practical recommendations for the implementation and evaluation of exercise services in this setting.
This article has been written for all clinicians seeking to embed exercise services as standard practice in cancer care. We detail the experiences of an AEP, to our knowledge, one of the first to be employed on a full-time basis within a cancer center in Australia (M.M.). On the basis of this case study, we provide practical recommendations for exercise professionals seeking to integrate exercise services within the cancer treatment setting. In addition, we present a model of care involving a key role for the exercise professional, which could be implemented to improve patient care and health outcomes throughout cancer treatment and beyond. Although our article is written from an Australian perspective, our recommendations may be relevant to and/or adapted for health care systems in other countries.
MICHAEL MARTHICK, ACCREDITED EXERCISE PHYSIOLOGIST, CHRIS O’BRIEN LIFEHOUSE
An AEP is a university-qualified exercise professional equipped with the knowledge, skills, and competencies to design, deliver, and assess exercise programs for people with acute or chronic medical conditions, including cancer (8). The scope of practice for an AEP also includes the provision of health education and lifestyle modification with a strong emphasis on achieving behavior change (9). Since December 2013, M.M. has served as the only AEP employed at the Chris O’Brien Lifehouse (Lifehouse), a nonprofit, integrated cancer center located in Sydney, Australia (www.mylifehouse.org.au). The position is based within the Supportive Care and Integrative Oncology Department, which provides evidence-based services from the Lifehouse Living Room (10). These services include exercise physiology, physiotherapy, yoga, nutrition, touch therapies (massage, reflexology), acupuncture, art therapy, counseling, and lymphedema therapy. Exercise physiology services are currently paid for fully by patients (fee for service) or subsidized via Medicare, private health insurance, donations, and research funding (10).
Integration of Exercise Services
Upon taking up the AEP position in late 2013, patient referrals to exercise physiology services were very slow, with the majority of patients self-referring. Realizing more internal promotion was needed to facilitate referrals, M.M. developed and executed an integration plan that targeted clinicians and patients. The plan included the following:
- Scheduling and attending private meetings with clinicians, including medical and radiation oncologists, surgeons, clinical nurses, and allied health care professionals to improve exercise oncology literacy
- Attending weekly multidisciplinary team meetings to discuss patient care and the evidence-based utility of exercise services in specific cases and/or cancer types
- Providing regular exercise in-services for clinicians. These in-services were also included within the orientation program for new Lifehouse staff, including nurses, physicians, and administrative personnel.
- Creating one-page topic sheets for clinical staff highlighting the benefits of exercise for specific treatment-related side effects/symptoms and referral pathways. Topic sheets were placed on walls in clinical consultation rooms for convenience.
- Providing free fitness testing, supervised exercise sessions, and exercise recommendations for Lifehouse staff, including oncologists and other clinicians
- Providing free 15- to 20-min consultations for patients referred immediately after a clinical review with their oncologist. These meetings took place adjacent to oncologists’ offices for easy transition. The scope of the meeting included discussion about current cancer treatments, exercise habits, barriers to uptake, and basic action plan.
- Inviting medical oncologists to visit their patients during participation in group exercise sessions
- Writing educational material on exercise oncology research and practice for the monthly staff newsletter circulated to all staff via the staff intranet and e-mail
The AEP’s current role at Lifehouse, including the percentage allocation for each duty, is presented in Table 1. The role primarily involves the delivery of primary exercise services, including individual exercise consultations, group exercise sessions, and remote exercise services (60%). Additional duties include delivering exercise support programs for specific groups (20%), conducting exercise-related research (10%), providing input on exercise-related services and events (5%), and liaising with external exercise professionals (5%) (Table 1).
Growth of Primary Exercise Services and Reflections
Primary exercise services have grown by 487% between 2014 and 2017, with the most significant period of growth occurring from 2015 to 2016 (+140%; Fig. 1). Currently, over 100 occasions of service (i.e., number of patient visits) are being provided in-center weekly. In addition, one to two remote exercise services are being provided weekly, i.e., delivered via video consultations and/or web portal (Table 1). Approximately two-thirds of the patients receiving primary exercise services via the Lifehouse Living Room are women (10). The majority of patients have a history of breast cancer (30%) followed by hematological cancer (20%), colorectal cancer (15%), prostate cancer (15%), head and neck cancer (10%), upper gastrointestinal cancer (5%), and brain cancer (5%). The average age of these patients is 57.5 yr (10).
At present, the AEP is working at full capacity with many patients on a waiting list to receive exercise services (10). There is now a need to expand AEP staffing and galvanize more in-house referrals via Lifehouse clinicians in alignment with the COSA position statement and growing recognition of the importance of exercise for cancer patients (7). Notably, only 5%–10% of patients attending Lifehouse receive exercise service(s) as part of their care. Barriers to patient uptake and clinician referral have been outlined previously (10). Efforts to address these barriers are ongoing and are primarily focused on improving patient and clinician exercise literacy, undertaking formal evaluation of existing services, using philanthropic donations to supplement or eliminate patient fees for exercise services, and seeking opportunities to integrate exercise directly into routine clinical care (e.g., exercise cycling during chemotherapy) (11).
RECOMMENDATIONS FOR EXERCISE PROFESSIONALS
On the basis of the experiences of M.M. at Lifehouse, we provide some practical recommendations for clinicians seeking to integrate exercise services in cancer care. We acknowledge that many of the elements of this section could be greatly expanded in stand-alone articles (i.e., the exercise prescription, behavior change strategies/support, and assessment selection). Our aim is to provide a brief and broad overview of the key elements.
In Australia, an AEP is qualified to work with cancer patients. An AEP has completed 4–5 yr of university education, including 360 h of clinical placement within a university program accredited by Exercise and Sports Science Australia. To our knowledge, university programs in exercise science (or equivalent) in other countries do not typically culminate in a professional degree. Therefore, individuals seeking to work in cancer care settings could ideally possess a university degree in exercise studies plus an appropriate specialist certification. The ACSM and the American Cancer Society have developed a comprehensive certification for delivering exercise services in cancer patients (i.e., the Certified Cancer Exercise Trainer). Prerequisites for this certification include a Bachelor’s degree in any field plus 500 h of experience training older adults or individuals with chronic conditions.
Streamlined referral pathways may facilitate continuity of care and can be developed by exercise professionals in consultation with oncology clinicians. One example of a streamlined referral system is Ex-Med Cancer (www.exmedcancer.org.au). This referral system is web-based and enables any health care professional to refer a cancer patient for exercise services. It also enables patient to self-refer. Once the referral has been received, the service provider makes contact with the patient. This approach is patient centered and involves minimum investment of time by clinicians or patients.
Reporting, Safety, and Team Care Approach
In Australia, an AEP is required to provide a written report to a physician who has referred a patient under the Medicare Benefits Schedule (9). The report typically outlines the brief medical history, assessment results, exercise-related considerations (e.g., modifications), prescription (i.e., the exercise management plan), and planned follow-up schedule. The general practitioner (GP) and other members of the care team can be kept informed on safety and progress. Effective communication between health care professionals is essential for the delivery of high-quality multidisciplinary team care (12). If exercise-related contraindications have been identified, or if adverse responses have occurred, the patient can be referred to the appropriate clinician for review. A safety reference guide that considers blood counts, cardiorespiratory signs and symptoms, bone metastases, and changes in physical and cognitive functioning has recently been published to support the safe delivery of exercise in cancer patients using a team care approach (13).
Improving Exercise Literacy in Clinicians
All clinicians, including the GP, specialist physicians, nurses, and allied health care professionals, can have a major impact on the adoption of physical activity in their patients (14). For example, it has been demonstrated that oncologists can significantly increase exercise adherence in their cancer patients through supportive statements (15) and behavior change tools (e.g., pedometers) (16). However, oncologists can often be inactive and lack basic knowledge about the application and benefits of exercise training (16,17).
Exercise professionals can help to improve the exercise literacy of oncology clinicians. Formal speaking engagements, including in-services and/or private meetings with clinicians, may be beneficial, along with using web-based approaches to disseminate pertinent clinical information (e.g., via social media pages, videos, blogs, Web sites, newsletters). In addition, providing clinicians the opportunity to directly experience professionally directed exercise services for themselves, e.g., via training sessions and/or assessments, may result in a greater appreciation of these services. Clinicians who are more physically active are more likely to endorse exercise (16).
Collectively, the education and qualifications of the exercise professional, the quality of referral pathways and diligence in reporting, and the strategies to enhance the exercise literacy of clinicians can likely all serve to enhance the utilization of exercise services by cancer patients.
The Initial Consultation
Exercise prescriptions should be individualized and patient centered (6), i.e., informed by the patient’s health history, current health status, and life circumstances, goals, preferences, and motivation (e.g., stage of behavior change). In our experience, a private consultation in a quiet office between the exercise professional and the patient and involving a friend or family member, if the patient so desires, is the best method to gain the insight required to create an effective, tailored exercise prescription. These consultations typically extend for 1 h or longer.
Exercise professionals can develop their own medical and health history forms and interviewing strategies (18) and build a program around specific goals, assessments, and rewards. The initial consultation may include the following.
Complete Medical and Health History
This may include a timeline (dates and durations) of all major diseases/illnesses, medical treatments received, significant changes in body weight, hospitalizations, physical trauma (accidents/injuries), and psychological trauma (including stress and anxiety). In addition, the cancer diagnosis (i.e., type, stage, and grade); the specific type, indication, and dosage of current and upcoming treatments for cancer and other comorbidities; the experience of acute and chronic side effects related to these treatments (e.g., fatigue, stress, anxiety, and depression); and the expected duration of treatment can be documented. Exercise professionals need to understand cancer therapies and that these are continually evolving (6). Factors potentially affecting exercise participation and acute and chronic responses to exercise in cancer patients have been summarized in Table 2.
Complete Exercise History
Previous experience engaging in exercise training (i.e., resistance training and aerobic training), sport, recreation, and leisure activities, along with periods of extended sedentary behavior, can be documented. Moreover, current exercise habits can be documented according to exercise prescription dosing variables (i.e., frequency, intensity, time, and type) such that these aspects could remain within, or be adapted for, the exercise prescription. It may be beneficial to note patient preferences for exercise type (modalities) and location (e.g., home or other) and modify the prescription accordingly.
Sleep and Diet
It is recommended that exercise professionals be aware of sleep deficits, which are common during cancer therapies (19), and monitor how the exercise prescription is influencing both sleep quality and duration. Exercise training can improve sleep dysfunction in cancer patients (20). If dietary and water intake are lacking, or there is a high intake of refined sugars (21) and processed foods (22,23) known to induce fat gain and chronic disease, basic dietary recommendations in alignment with accepted guidelines can be offered by the exercise professional, as per the scope of practice for an AEP in Australia (9). However, nutritional care in cancer patients can be complex, and therefore referral to a dietitian for more detailed assessment and treatment plan may be warranted. For example, malnutrition can arise from treatment of head and neck (24) and gastrointestinal cancers (25), whereas the need to lose body fat may be of major concern in certain cancers, such as breast, where obesity is associated with a poorer prognosis and treatment outcomes (26).
Barriers to Exercise
A key element to successful adoption and maintenance of exercise is the identification of barriers and the outlining of specific strategies to overcome these barriers. Barriers in cancer patients can be general (e.g., lack of time/resources, family obligations, lack of social support, weather, etc.), cancer specific (e.g., concerns over safety, fear of exacerbating symptoms, lack of physician support, etc.), and psychologically rooted (e.g., lack of confidence and self-efficacy) (27–29). Motivational interviewing involves guiding the conversation and allowing the patient to identify their own solutions to perceived barriers, and this technique may potentially improve exercise adherence (27–29).
Social Support and Roles
Influential family and friends may help to facilitate behavior change (via partnering, motivational cuing, etc.). Understanding the role of the patient within the family may be important for increasing engagement in routine activities within the home and identifying opportunities for increasing physical activity outside the home (e.g., “I have time to walk around the soccer field while my kids have soccer practice on Tuesday and Thursday”). If the patient is currently employed or has other duties (i.e., as a caregiver or volunteer), the nature of the role and weekly schedule can be discussed to identify scheduling gaps, i.e., opportunities to engage in exercise or physical activity. This may be particularly important for those exposed to extended periods of inactivity.
Goals and Rewards
Discussing life aspirations is important for the identification of intrinsic and extrinsic motivators and the development of both short- and long-term goals. Goal setting involving SMART goals aligned with the assessment outcomes, program adherence, and rewards system is important for stimulating motivation, compliance, enjoyment, and improvement (30).
Preexercise and Ongoing Assessments
Preexercise, medical, and exercise-related assessments in cancer patients have been outlined by the ACSM (6). Assessments can also be undertaken to evaluate physiological, functional, and/or psychological adaptations to the exercise prescription. The selection of assessments can be patient centered, i.e., informed by the patient’s goals and health impairments, including current- and potential treatment-related side effects (e.g., bone demineralization caused by use of aromatase inhibitors). Multiple clinicians can be involved in the collection of assessments. For example, an endocrinologist could schedule the collection of routine blood tests in a patient with metabolic syndrome to align with the exercise prescription timeline. It is recommended that the time course for repeat assessments is evidence supported, as to not waste resources and/or overburden the patient and exercise professional.
Several assessments, including cardiorespiratory fitness, muscle mass (e.g., body composition), and general HRQoL, have relevance and could be collected across all cancer patients (6). In clinical practice, gold standard assessments for cardiorespiratory fitness (i.e., peak oxygen consumption, V˙O2peak) and muscle mass (via dual-energy x-ray absorptiometry) would be ideal, but resources and budgets may limit collection in clinical practice, and hence surrogate measures could be collected. The Medical Outcomes Trust Short Form-36 (SF-36) survey (31) is a generic HRQoL instrument that has been validated and used in clinical research and practice globally, and specific domains (e.g., physical function and vitality) have been shown to be sensitive to change in exercise oncology research. Disease-specific instruments can also be used to assess the impact of specific cancers and their treatments on HRQoL.
Exercise and Physical Activity Prescription
Our recommendations for the exercise and physical activity prescription align with position statements (5,6) and are also informed by our experience in research and clinical settings (Table 3). The exercise prescription should include robust training modalities (e.g., resistance and aerobic training) applied using fundamental training principles (32). A list of daily activities can also be provided to engage the patient with their role in life (e.g., domestic duties, work duties, care duties) as this is a fundamental aspect of rehabilitation (33). In addition, leisure-time activities that will inspire the patient toward lifelong physical activity can be outlined and included. Such leisure-time activities may overlap with and therefore contribute to the aerobic training prescription. If desired by the patient, the prescription can emphasize social engagement (34) and time in nature (35) as these elements are known to improve adherence, extending the benefits of exercise and physical activity.
Ideally, resistance training sessions should be supervised, at least for the initial 2–3 months, to develop proper movement patterns (technique) that are essential to prevent the occurrence of musculoskeletal injuries, which have been reported in some trials (36). Alternatively, if appropriate, resistance training prescriptions can be provided to patients to be undertaken unsupervised on their own at home or in a facility or their choice. However, in our experience, unsupervised resistance training can often result in insufficient loading, poor technique, low compliance, and therefore suboptimal benefits in inexperienced lifters.
All aerobic training can be informed by the patient’s exercise modality preferences. Moderate to higher intensities of aerobic training may be ideally undertaken with supervision in inexperienced patients initially (e.g., ~2–3 months), particularly those with chemotherapy-induced cardiotoxicity, cardiovascular risk factors, or known cardiovascular disease. Unsupervised training (as appropriate) can be encouraged on a daily basis to foster habitual activity and behavior change as required. Walking is often the most viable and preferred mode of aerobic training for many cancer patients (37), and it can often be undertaken without supervision, even in advanced cancers (38). However, as per all aerobic training prescriptions, the unsupervised walking program should include progressions in frequency, duration (i.e., by documenting walking time or step counts), and/or intensity (i.e., by increasing walking speed or exposure to inclines, i.e., hills) over time for ongoing benefits.
Dynamic and static stretching can be included within resistance training warm-up and cooldown procedures, respectively, to supplement improvements in joint ranges of motion achieved through dynamic resistance exercises. Additional stretching can be prescribed up to 7 d·wk−1 to address range of motion deficits induced by cancer therapies, aging, disuse, and a combination thereof.
An important component of behavior change is encouraging independent participation (autonomous practice), which includes the systematic titration away from supervised exercise sessions. In particular, individuals who are new to exercise can be encouraged to explore different exercise and self-regulatory strategies on their own. Reduced dependence on the exercise supervisor may aid in the long-term maintenance of exercise and related lifestyle changes (39). An overview of theories and strategies to promote successful adoption and maintenance of activity has been outlined elsewhere (40).
Monitoring and Progression
Accurate monitoring of each training session, including comparing planned (prescribed) versus completed (actual) exercise sessions, is essential for ensuring safety and progress. For example, a planned resistance training session may have involved 10 exercises performed for two sets by 8–12 repetitions maximum each, but pain may have limited the patient’s ability to train, e.g., the individual completed only one set of five exercises with light (suboptimal) loads. Documenting planned and completed exercise sessions may more effectively inform adjustments in the prescription to accommodate acute symptomatic fluctuations (41).
Autoregulation can also be applied to adjust the exercise prescription as needed (42). There are numerous ways to apply autoregulation within a training program, e.g., to adjust intratraining loads, to progress from week to week, or to select a set/repletion or duration/intensity scheme before the exercise session (42). This can be done using scales to assess energy, recovery, or sleep before a session, or using a perceived exertion scale to adjust intrasession load. These are readily used methods of adjusting training that are beginning to be investigated in exercise oncology research (43). Autoregulatory strategies within a properly periodized training model will likely reduce the risk of injury (due to fatigue, overtraining, etc.), minimize mental staleness, and promote long-term adoption of exercise (42,43).
The adoption of innovative technology tools to improve clinician and patient contact and monitoring in exercise oncology is rapidly advancing. This includes opportunities to provide remote monitoring of exercise behaviors using wearable technologies (e.g., pedometers) and online portals (44) through to full telerehabilitation programs (45). Such innovative methods could be implemented to improve patient access and monitoring.
AN INTEGRATED MODEL OF CARE
Thirty-five years of empirical research culminating in clinical guidelines and position statements has demonstrated that exercise can be integrated as standard practice in cancer care, across all cancers, and be viewed as an adjunct therapy that helps counteract the adverse effects the disease and its treatment (7). In Figure 2, we present an integrated and patient-centered model of care to enhance health outcomes both during and beyond cancer treatment. This model of care is currently being implemented and refined at the Chris O’Brien Lifehouse. In this model, we propose that exercise professionals employed within the cancer center itself can play a major role in the long-term care of cancer patients. Exercise services, by their nature, require an individualized (patient-centered) approach that involves extended consultations, long-term planning, consistent and periodic contact, and the input of other health care professionals. In Australia, the scope of practice of an AEP positions them optimally to take on the role of the “supportive care navigator” for patients who are undergoing intensive cancer treatment (or in palliative care) and looking toward maintaining and/or improving HRQoL.
We propose that the referral for exercise services can ideally come from the consulting oncologist given that these physicians are directing the cancer treatment. Oncologists have the duty of care to inform the patient about both the positive and the negative effects of their treatments and the best-practice approaches to mitigate symptoms and maintain and improve their health status and HRQoL. Exercise is likely the most evidence-supported intervention that an oncologist can recommend in this regard (7). In Australia, the referral for Medicare-supported services must be provided by the GP. In such instances, the oncologist could provide a written recommendation for the GP to refer a patient to an AEP under the appropriate Medicare scheme.
Individuals with cancer will have psychological, musculoskeletal, and nutritional concerns that will require the expertise of other health care professionals. Ideally, as at Lifehouse (10), these professionals would also be embedded within the cancer center itself (Fig. 2). Referrals to other health care professionals could be made by the exercise professional, as identified in the first consultation with the patient. A comprehensive, but realistic, suite of therapies to complement the exercise program will likely provide patients with the best possible outcomes during their cancer treatments.
Transitioning back to the community: The in-center exercise physiologist could be in an ideal position to enhance continuity of care from the clinical setting to the community. This continuity of care could be facilitated by identifying and creating a network of community-based exercise professionals who can best address the needs of cancer patients and survivors. Referrals to community-based exercise professionals could take place at any time point along the cancer continuum, informed by patient preference. Such an approach may lead to better health outcomes, HRQoL, and survival prospects for any given patient over the long term.
FUTURE TRANSLATIONAL RESEARCH
We have presented evidence and recommendations for the inclusion of exercise professionals within the cancer center and have outlined a model of care that is realistic and currently being implemented and refined at the Chris O’Brien Lifehouse. The implementation of this model, or an adaptation thereof, could potentially result in better continuity of care and health outcomes for patients throughout their treatment journey and beyond. Therefore, the main avenue for a formal translational research program would be to investigate the feasibility and effectiveness of such a model of care in all its aspects. We are planning to undertake such research at the Lifehouse. Such research initiatives could enhance the implementation and refinement of exercise services more broadly in cancer treatment settings. Moreover, research into the cost-effectiveness of such programs could provide valuable information to policymakers and third-party payers and provide support for reimbursement. We suggest that a comprehensive translational research program needs to be undertaken if cancer patients are to truly benefit from the research efforts put forth in previous decades.
BSC is the guarantor of the article, taking responsibility for the integrity of the work as a whole, from inception to published article. BSC, CF, and MM conceived and drafted the manuscript. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The views expressed in this article do not constitute endorsement by the ACSM.
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