General and Supportive Care
Evidence-based physical activity guidelines for cancer survivors: Current guidelines, knowledge gaps and future research directions

https://doi.org/10.1016/j.ctrv.2013.06.007Get rights and content

Abstract

Physical activity during and after cancer treatment has beneficial effects on a number of physical and psychosocial outcomes. This paper aims to discuss the existing physical activity guidelines for cancer survivors and to describe future research directions to optimize prescriptions. Studies on physical activity during and after cancer treatment were searched in PubMed, Clinicaltrials.gov, Australian New Zealand Clinical Trials Registry, and Dutch Trial registry. Physical activity guidelines for cancer survivors suggest that physical activity should be an integral and continuous part of care for all cancer survivors. However, the development of these guidelines has been limited by the research conducted. To be able to develop more specific guidelines, future studies should focus on identifying clinical, personal, physical, psychosocial, and intervention moderators explaining ‘for whom’ or ‘under what circumstances’ interventions work. Further, more insight into the working mechanisms of exercise interventions on health outcomes in cancer survivors is needed to improve the efficacy and efficiency of interventions. Finally, existing programs should embrace interests and preferences of patients to facilitate optimal uptake of interventions. In conclusion, current physical activity guidelines for cancer survivors are generic, and research is needed to develop more personalized physical activity guidelines.

Introduction

In developed countries, approximately one in three persons will be directly affected by cancer before the age of 75 years, with breast cancer, prostate cancer, lung cancer and colorectal cancer the most common diagnoses [1]. It has been estimated that 12.7 million cancer cases and 7.6 million cancer deaths occurred worldwide in 2008 [1]. Advances in early detection and treatment have improved survival rates over the past decades, with approximately 60% of patients living over 5 years after diagnosis [2], [3]. However, cancer and its treatment are often associated with physical and psychosocial problems, negatively affecting quality of life (QoL) [4], [5].

Anyone who has been diagnosed with cancer, from the time of diagnosis through the rest of life, is considered a cancer survivor [6]. Several reviews and meta-analyses demonstrate beneficial effects of physical activity (PA) and exercise (i.e. form of PA that is planned, structured and repetitive and aims to improve fitness, performance or health [7]) in cancer survivors during and after treatment on physical and psychosocial outcomes, [8], [9] including increased aerobic fitness, [10] reduced fatigue [11], [12] and depression, [13] and improved QoL [14], [15]. Sufficient levels of PA may also be important to improve disease free and overall survival. Observational studies showed higher levels of moderate-to-vigorous PA to be associated with lower mortality risk in survivors [16] of breast, [17], [18], [19] colon, [20], [21] and prostate cancer, [22], [23] with physically active survivors having approximately 50% lower mortality. However, to establish a causal relationship between PA and survival, randomized controlled trials (RCTs) are needed. The first RCT evaluating the effects of PA on survival is currently being conducted among survivors with colon cancer who have completed adjuvant chemotherapy in the Colon Health and Life-Long Exercise Change (CHALLENGE) trial [24].

Given the increasing number of studies showing the safety and benefits of PA, it should be part of standard care for all cancer survivors. Evidence-based PA guidelines have been published, but the development of these guidelines is limited by the research conducted in this area. This paper reviews the current evidence-based PA guidelines for cancer survivors, identifies current knowledge gaps and describes the research needed to fill these gaps. This synopsis may inform future studies evaluating exercise as medicine for cancer, as well as the development of more personalized PA guidelines for cancer survivors.

Section snippets

Current guidelines and their empirical basis

In 2003, the American Cancer Society (ACS) published a report intended to present health care providers with the best possible information on which to assist cancer survivors and their families to make informed choices related to nutrition and PA [25]. This was ACS’s second report on nutrition, but the first to also include information on PA. Although evidence was generally insufficient to draw conclusions about the benefits and risks of PA, a probable beneficial effect of PA on QoL was found

Knowledge gaps to be addressed

Although the significant work conducted to formulate the above mentioned guidelines is important and has changed clinical practice for management of cancer, current recommendations are rather general due to gaps in specific areas of exercise oncology. The ultimate aim is to have specific guidelines to inform a given exercise intervention (e.g. mode, frequency, intensity, duration), for a given cancer site at a particular phase of the cancer trajectory (e.g. during treatment, survivorship, end

Conclusions

Current PA guidelines for cancer survivors are generic. It is necessary to move from a one-size fits all approach to specific PA guidelines tailored to the characteristics, needs, capabilities and preferences of individual patients. More research is needed to be able to develop specific guidelines for a given exercise prescription (e.g. mode, frequency, intensity, duration), for a given cancer site at a particular phase of the cancer trajectory, disease impact and treatment side-effects, and

Conflict of interest statement

All authors have declared no conflicts of interest.

Authorship

All authors have made a substantial contribution to the conception and design of the study, drafting or critically revising the manuscript, and approved the version to be submitted.

Acknowledgements

The contribution of LMB was funded by a ‘Bas Mulder’ grant of the Alpe d’HuZes foundation, which is part of the Dutch Cancer Society, a fellowship granted by the EMGO Institute for Health and Care Research, and a travel grant funded by the Edith Cowan University.

The contribution of DAG was funded by a Movember New Directions Development Award obtained through Prostate Cancer Foundation of Australia’s Research Program. All sponsors had no involvement in the content of the manuscript and in the

References (147)

  • C. Schubert et al.

    The association between fatigue and inflammatory marker levels in cancer patients: a quantitative review

    Brain Behav Immun

    (2007)
  • B.K. Pedersen

    Exercise-induced myokines and their role in chronic diseases

    Brain Behav Immun

    (2011)
  • A. Jemal et al.

    Global cancer statistics

    CA Cancer J Clin

    (2011)
  • Australian Institute of Health and Welfare. Cancer survival and prevalence in Australia. Cat no CAN 38, 2008,...
  • IKCnet. Dutch Cancer Registration. Survival. <http://www.ikcnet.nl>;...
  • K.S. Courneya

    Exercise in cancer survivors: an overview of research

    Med Sci Sports Exerc

    (2003)
  • G.A. Curt et al.

    Impact of cancer-related fatigue on the lives of patients: new findings from the Fatigue Coalition

    Oncologist

    (2000)
  • Centers for Disease Control and Prevention (CDC)

    Cancer survivors – United States, 2007

    MMWR Morb Mortal Wkly Rep

    (2011)
  • C.J. Caspersen et al.

    Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research

    Public Health Rep

    (1985)
  • J.Y.T. Fong et al.

    Physical activity for cancer survivors: a meta-analysis of randomised controlled trials

    BMJ

    (2012)
  • R.M. Speck et al.

    An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis

    J Cancer Surviv

    (2010)
  • L.W. Jones et al.

    Effect of exercise training on peak oxygen consumption in patients with cancer: a meta-analysis

    Oncologist

    (2011)
  • F. Cramp et al.

    Exercise for the management of cancer-related fatigue in adults

    Cochr Database Syst Rev

    (2012)
  • L.L. Craft et al.

    Exercise effects on depressive symptoms in cancer survivors: a systematic review and meta-analysis

    Cancer Epidemiol Biomarkers Prev

    (2012)
  • S.I. Mishra et al.

    Exercise interventions on health-related quality of life for people with cancer during active treatment

    Cochr Database Syst Rev

    (2012)
  • S.I. Mishra et al.

    Exercise interventions on health-related quality of life for cancer survivors

    Cochr Database Syst Rev

    (2012)
  • R. Ballard-Barbash et al.

    Physical activity, biomarkers, and disease outcomes in cancer survivors: a systematic review

    J Natl Cancer Inst

    (2012)
  • M.D. Holmes et al.

    Physical activity and survival after breast cancer diagnosis

    JAMA

    (2005)
  • M.L. Irwin et al.

    Physical activity and survival in postmenopausal women with breast cancer: results from the Women’s Health Initiative

    Cancer Prev Res

    (2011)
  • K.H. Schmitz

    Exercise for secondary prevention of breast cancer: moving from evidence to changing clinical practice

    Cancer Prev Res

    (2011)
  • J.A. Meyerhardt et al.

    Physical activity and survival after colorectal cancer diagnosis

    J Clin Oncol

    (2006)
  • J.A. Meyerhardt et al.

    Physical activity and male colorectal cancer survival

    Arch Intern Med

    (2009)
  • S.A. Kenfield et al.

    Physical activity and survival after prostate cancer diagnosis in the health professionals follow-up study

    J Clin Oncol

    (2011)
  • E.L. Richman et al.

    Physical activity after diagnosis and risk of prostate cancer progression: data from the cancer of the prostate strategic urologic research endeavor

    Cancer Res

    (2011)
  • K.S. Courneya et al.

    The colon health and life-long exercise change trial: a randomized trial of the national cancer institute of Canada clinical trials group

    Curr Oncol

    (2008)
  • J.K. Brown et al.

    Nutrition and physical activity during and after cancer treatment: an American cancer society guide for informed choices

    CA Cancer J Clin

    (2003)
  • C. Doyle et al.

    Nutrition and physical activity during and after cancer treatment: an American cancer society guide for informed choices

    CA Cancer J Clin

    (2006)
  • K.H. Schmitz et al.

    American college of sports medicine roundtable on exercise guidelines for cancer survivors

    Med Sci Sports Exerc

    (2010)
  • Physical Activities Guidelines Advisory Committee

    Physical activity guidelines advisory committee report

    (2008)
  • Comprehensive Cancer Center the Netherlands. Guideline cancer rehabilitation....
  • J.P. van den Berg et al.

    Richtlijn ‘Oncologische revalidatie’ [guideline cancer rehabilitation]

    Ned Tijdschr Geneeskd

    (2011)
  • C.N. Steins Bisschop et al.

    Cardiopulmonary exercise testing in cancer rehabilitation. A systematic review

    Sports Med

    (2012)
  • C.L. Rock et al.

    Nutrition and physical activity guidelines for cancer survivors

    CA Cancer J Clin

    (2012)
  • A. Campbell et al.

    The BASES expert statement on exercise and cancer survivorship

    J Sports Sci

    (2012)
  • F.C. Bull et al.

    Physical activity guidelines in the U.K.: review and recommendations

    (2010)
  • F. Cramp et al.

    Exercise for the management of cancer-related fatigue in adults

    Cochr Database Syst Rev

    (2008)
  • S.F. Duijts et al.

    Effectiveness of behavioral techniques and physical exercise on psychosocial functioning and health-related quality of life in breast cancer patients and survivors – a meta-analysis

    Psychooncology

    (2011)
  • H.C. Kraemer et al.

    Mediators and moderators of treatment effects in randomized clinical trials

    Arch Gen Psychiatry

    (2002)
  • K.S. Courneya et al.

    Moderator effects in a randomized controlled trial of exercise training in lymphoma patients

    Cancer Epidemiol Biomarkers Prev

    (2009)
  • K.S. Courneya et al.

    Moderators of the effects of exercise training in breast cancer patients receiving chemotherapy: a randomized controlled trial

    Cancer

    (2008)
  • Cited by (202)

    View all citing articles on Scopus
    1

    Tel.: +61 8 6304 3420; fax: +61 8 6304 2499.

    2

    Tel.: +31 20 444 8192; fax: +31 20 444 8171.

    3

    Tel.: +31 20 444 8203; fax: +31 20 444 8387.

    4

    Tel.: +61 8 6304 3443; fax: +61 8 6304 5106.

    View full text