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Exercise as a Standard of Care in Oncology Rehabilitation

Harsh Reality Versus Aspiration

Morris, G. Stephen, PT, PhD, FACSM

doi: 10.1097/01.REO.0000000000000139
PRESIDENT'S PERSPECTIVE

President, Oncology Section, APTA; and Distinguished Professor, Department of Physical Therapy, Wingate University, Wingate, NC

Correspondence: G. Stephen Morris, PT, PhD, FACSM, Department of Physical Therapy, Wingate University, Wingate, NC 28174 (s.morris@wingate.edu).

The author declares no conflicts of interest

In May 2018, the Clinical Oncology Society of Australia (COSA) issued a position statement calling for (1) exercise to be embedded as a standard practice in the care of all cancer survivors, (2) exercise to be viewed as an adjuvant therapy, and (3) survivors should be referred to health care professionals who specialize in the prescription and delivery of exercise including accredited exercise physiologists and/or physiotherapists.1 COSA has joined a growing number of organizations (American Cancer Society, American College of Sports Medicine, National Comprehensive Cancer Network, and the Oncology Nursing Society) that strongly support the use of exercise in the treatment of cancer survivors. While truly aspirational, COSA remains alone in the reach and aggressiveness of its call for making exercise a standard of care in the medical management of cancer survivors.2 I truly wish that exercise was a standard of care; however, I am forced to argue that this position statement is, at best, premature. I don't believe we have the data or practice behaviors necessary to embed exercise as part of a standard of care. Please let me explain.

The National Cancer Institute (NCI) defines standard care as “treatment that is accepted by medical experts as a proper treatment for a certain type of disease and that is widely used by healthcare professionals.”3 Surprising as it may be, recommending exercise as a treatment option for the cancer survivor is not as universal as physical therapists might like to believe. The 2009 statement by the Australian Association for Exercise and Sport Science supporting the use of exercise to achieve optimal cancer outcomes noted that incorporating exercise in the management of the cancer survivor “was not a philosophy held by all,” with resistance to doing so arising from clinicians and other allied health professionals.4 These authors argued that this position was the result of a “lack of understanding with respect to what an individualized exercise program means.”3 Ten years later, Brown and Schmitz5 reported that 84% of oncologists do not prescribe exercise, citing concerns for patient safety and feasibility of exercise as an intervention. Add to these reports, anecdotal statements from clinicians stating frustration with an inability to get referrals from physicians for exercise interventions, it would seem that the therapeutic use of exercise training in the survivor population fails to meet the NCI requirement that treatments considered to be standards of care be widely used by health care professionals.

In the same vein, the NCI defines a standard of care as being “proper treatment.”3 While we can strongly argue that exercise is a proper treatment intervention for survivors, we cannot describe what constitutes proper exercise treatment for each of the many individual diseases that constitute cancer. An exercise dose or volume is defined by characteristics of the exercise itself and the exercise session, frequently referred to as FITT: F—frequency of exercise, I—intensity of exercise, T—time of exercise session, and T—type of exercise. Manipulating these characteristics defines the dose of the exercise and if the dose is sufficiently great, most organ systems of the individual performing the exercise will positively adapt to the exercise.6 While some cancer survivors can adapt to exercise in a dose-dependent fashion,6 , 7 the dose or volume of exercise needed to achieve such results is not known for the overwhelming majority of cancer diagnoses. Again, the point is that exercise interventions are important therapeutic interventions, but data needed to elevate exercise to a standard of care for most survivors with cancers are not available, making this call by COSA premature. Currently, writing safe and efficacious exercise-based treatment plan remains dependent, largely, on the clinical decision-making skills of the individual clinician.

As noted by Alfano et al,8 the credentials of those providing exercise supervision to cancer survivors should be dependent on the health status of the survivor. Many community-based cancer rehabilitation programs effectively provide exercise training, employing staff who have limited formal training in providing exercise training to cancer survivors but do have experience or specific certifications. Such programs are important and succeed by limiting their participants to survivors without medical complications and suffer almost exclusively from deconditioning. As the health status of survivors becomes increasingly more complex, minimum qualifications for appropriate providers become more rigorous, increasing from exercise physiologists and physical therapist generalists to physical therapists with advanced training (specialization) to physical therapists with advanced training working alongside rehabilitation physicians. This “stepped model” of providing exercise supervision to cancer survivors conflicts with the recommendations of COSA that only exercise physiologists and physiotherapists should provide exercise as a treatment intervention. The stepped model appropriately matches health care provider with patient needs, thus making better use of available resources than that suggested by the COSA statement.

Currently, cancer survivors are encouraged to engage in 150 minutes per week of moderate exercise, 2 sessions of resistance training per week, and flexibility activities. When achieving these goals is not possible, the cancer survivor is encouraged to be as active as possible.6 Our hope is that soon more specific disease and grade-specific recommendations will be available so that an exercise prescription can be truly personalized. Until that time, the ambitious calls of COSA remain long-term goals rather than a treatment plan.

Thank you, once again, for reading my ramblings and, by all means, get your patients to keep on exercising!!!

Cheers.

G. Stephen Morris, PT, PhD, FACSM

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REFERENCES

1. Cormie P, Atkinson M, Bucci L, et al Clinical Oncology Society of Australia position statement on exercise in cancer care [published online ahead of print May 7, 2018]. Med J Aust. doi:10.5694/mja18.00199.
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3. National Cancer Institute. NCI dictionary of cancer terms. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/standard-of-care. Accessed July 9, 2018.
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8. Alfano CM, Cheville AL, Mustian K. Developing high-quality cancer rehabilitation programs: a timely need. In: Dizon DS, ed. 2016 ASCO Educational Book. Arlington, VA: American Society of Clinical Oncology; 2016:143–179.
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