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