Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable

In the paper

“Moderate intensity combined aerobic plus resistance training sessions performed 2–3 times per week or twice weekly moderate intensity resistance training may also be effective(21, 24–26), and the latter particularly in prostate cancer(27).”

What the sources say

• Not checked yetcites [21] source
• Not checked yetcites [24] source
• Partly supported

  The Results (page unavailable) report reduced fatigue in two resistance-training programs, and the Abstract recommends two to three resistance-training bouts per week for men with prostate cancer. The citation is attached to the sentence’s latter option—resistance training—not the combined aerobic-plus-resistance option in the supplied claim. Our copy does not establish that combined training at moderate intensity two to three times weekly reduces fatigue. (LLM, conf=0.86)

  cites [25] sourceExperimental — accuracy not yet measured
• Partly supported

  The Results (Intervention and Control Conditions; page not available in our copy) report that 20 studies tested combined aerobic and anaerobic exercise. The Results (Meta-analysis Main Effects; page not available) find that exercise improved cancer-related fatigue and that effectiveness was not associated with exercise mode. The paper does not establish the claimed moderate intensity or 2–3-times-weekly schedule. (LLM, conf=0.86)

  cites [26] sourceExperimental — accuracy not yet measured

In the paper

“standard fall prevention exercise approaches that reduce the risk of age-related falls”

What the sources say

• ?Could not verify

  The Discussion (page unavailable) discusses exercise and fracture risk, but does not report whether exercise reduces falls. Searches for fall prevention, fall incidence, and balance found no passage addressing the claimed reduction in age-related falls. (LLM, conf=0.76)

  cites [60] sourceExperimental — accuracy not yet measured
• ?Could not verify

  The Lower body strength section reports improved strength in men with prostate cancer, but does not assess whether exercise prevents age-related falls. Section 3.4 mentions a fall as an adverse event, not a fall-prevention outcome. Searches for fall prevention and reduced fall risk found no passage supporting the claim. (LLM, conf=0.72)

  cites [61] sourceExperimental — accuracy not yet measured

In the paper

“Recently, the ACSM updated its pre-participation exercise guidelines for all persons in an attempt to reduce barriers to exercise by removing a requirement for medical clearance for individuals whose risk of an adverse cardiac event during exercise are low, including exercise naïve persons(85).”

What the sources say

• Supported

  The New Exercise Preparticipation Health Screening Process Algorithm states that physically inactive, otherwise healthy asymptomatic people may begin light- to moderate-intensity exercise without medical clearance. The New ACSM Exercise Preparticipation Health Screening Recommendations explains that the changes aim to avoid unnecessary barriers to exercise. The exemption does not extend to inactive people with relevant symptoms or known cardiovascular, metabolic, or renal disease. (LLM, conf=0.91)

  cites [85] source

In the paper

“Based on results from high quality trials of aerobic training, there may be a dose-response effect where higher volumes of aerobic exercise (90 min vs. up to 180 min/week) leads to better symptom reduction.”

In the paper

“Based on sufficient evidence, resistance training alone does not seem to be effective for this outcome.”

In the paper

“Based on sufficient evidence, it does not appear that resistance training alone reduces anxiety.”

In the paper

“Moderate intensity combined aerobic plus resistance training sessions performed 2–3 times per week or twice weekly moderate intensity resistance training may also be effective(21, 24–26), and the latter particularly in prostate cancer(27).”

What the sources say

• Not checked yetcites [27] source

In the paper

“The effect of exercise was strongest for moderate to vigorous intensity exercise whereas the effect for low intensity training was weak and this level of exercise is unlikely to reduce fatigue(22, 24, 26, 28).”

What the sources say

• Not checked yetcites [22] source
• Not checked yetcites [24] source
• Not checked yetcites [26] source
• Not checked yetcites [28] source

In the paper

“Improvements in anxiety appear to be greater in supervised training programs or those having a larger supervised component than those that are predominantly unsupervised or home-based.”

In the paper

“A dose of moderate intensity aerobic training three times per week for 12 weeks or twice weekly combined aerobic plus resistance training for 6–12 weeks can significantly reduce anxiety in cancer survivors during and after treatment(13–17).”

What the sources say

• Not checked yetcites [13] source
• Not checked yetcites [14] source
• Not checked yetcites [15]
• Not checked yetcites [16] source
• Not checked yetcites [17] source

In the paper

“There is not sufficient evidence to determine whether or not there is a dose response relationship between exercise intensity and changes in anxiety.”

In the paper

“Improvements in depressive symptoms appear to be greater in supervised training programs or those having a larger supervised component than those that are predominantly unsupervised or home-based.”

In the paper

“For training programs that last at least 12 weeks, engaging in moderate intensity aerobic training three times per week can significantly reduce cancer-related fatigue both during and after treatment(20–23).”

What the sources say

• Not checked yetcites [20]
• Not checked yetcites [21] source
• Not checked yetcites [22] source
• Not checked yetcites [23]

In the paper

“Whether or not more exercise translates to less cancer-related fatigue remains unclear, though there is suggestive evidence that the reductions in fatigue are greater with exercise sessions longer than 30 minutes and programs longer than 12 weeks compared to less exercise(29).”

What the sources say

• Not checked yetcites [29] source

In the paper

“Moderate intensity aerobic training, resistance training or combined aerobic plus resistance training performed three times weekly for 8–12 weeks can significantly improve self-reported physical function(31, 32, 44).”

What the sources say

• Not checked yetcites [31] source
• Not checked yetcites [32] source
• Not checked yetcites [44] source

In the paper

“Improvements in HRQoL appear to be greater in supervised training programs or those having a larger supervised component than those that are predominantly unsupervised or home-based.”

In the paper

“Insufficient evidence exists to conclude whether or not starting a resistance training program without supervised instruction is safe for women with or at risk for lymphedema after breast cancer.”

In the paper

“Broadly, supervised exercise appears to be more effective than unsupervised or home-based interventions(32), although unsupervised programs may be effective in older cancer survivors(44).”

What the sources say

• Not checked yetcites [44] source

In the paper

“In general, aerobic exercise seems to be safe, with no significant increase in number of lymphedema-related adverse events reported in studies investigating aerobic exercise(17).”

What the sources say

• Not checked yetcites [17] source

In the paper

“Broadly, supervised exercise appears to be more effective than unsupervised or home-based interventions(32), although unsupervised programs may be effective in older cancer survivors(44).”

What the sources say

• Not checked yetcites [32] source

In the paper

“To date, there is insufficient evidence to draw conclusions for aerobic exercise.”

In the paper

“For resistance training, a general progressive program focused on large muscle groups performed 2–3 times per week, with the principle of “start low, progress slow” is safe when supervised by a fitness professional(38–42).”

What the sources say

• Not checked yetcites [38] source
• Not checked yetcites [39] source
• Not checked yetcites [40] source
• Not checked yetcites [41] source
• Not checked yetcites [42] source

In the paper

“Combined moderate intensity aerobic and resistance exercise performed 2–3 times per week for at least 12 weeks results in improvements in HRQoL both during and after treatment(17, 31, 32).”

What the sources say

• Not checked yetcites [17] source
• Not checked yetcites [31] source
• Not checked yetcites [32] source

In the paper

“The effect of exercise was strongest for moderate to vigorous intensity exercise whereas the effect for low intensity training was weak and this level of exercise is unlikely to reduce fatigue(22, 24, 26, 28).”

What the sources say

• Not checked yetcites [22] source
• Not checked yetcites [24] source
• Not checked yetcites [26] source
• Not checked yetcites [28] source

In the paper

“The efficacy of exercise for this outcome appears to be independent of the level of supervision and/or setting for training(21, 27, 30).”

What the sources say

• Not checked yetcites [21] source
• Not checked yetcites [27] source
• Not checked yetcites [30] source

In the paper

“The benefit of combined aerobic plus resistance training programs appears more potent than programs consisting of only aerobic or resistance training(32).”

What the sources say

• Not checked yetcites [32] source

In the paper

“The majority of research to date has been in men with prostate cancer(65, 66)”

What the sources say

• Not checked yetcites [65] source
• Not checked yetcites [66] source

In the paper

“When interpreting and applying a prescription, the exercise professional should be mindful that the evidence is often disproportionately from trials in a single cancer type (i.e., breast), but the prescription is assumed to generalize across cancer types unless otherwise specified.”

In the paper

“Four recent RCTs not included in either systematic review have shown consistent evidence of small to moderate effect sizes on overall sleep quality for aerobic training(51), in addition to walking specifically(52, 53) and one study reported evidence of benefit for resistance training(31).”

What the sources say

• Not checked yetcites [51] source
• Not checked yetcites [52] source
• Not checked yetcites [53] source
• Not checked yetcites [31] source

In the paper

“It should be noted that these results are based on self-reported physical function, not objective measures where the evidence base on these outcomes remains immature and more challenging to aggregate due to the variation and limitations of assessment techniques.”

In the paper

“there is limited data from high quality trials with nausea as a primary endpoint to support this finding outside of an early study demonstrating a reduction by Winningham et al.(62).”

What the sources say

• Not checked yetcites [62] source

In the paper

“The effects of exercise on treatment tolerance for radiation therapy, hormonal therapy (i.e., aromatase inhibitors or androgen deprivation therapy), targeted therapies or immunotherapy is currently unknown.”

In the paper

“there has historically been incomplete reporting of compliance to a prescribed FITT program in published studies, likely because tracking and quantifying compliance can be burdensome (74–76).”

What the sources say

• Not checked yetcites [74] source
• Not checked yetcites [75]
• Not checked yetcites [76] source

In the paper

“To date, there are too few high quality trials to interpret the potential of the benefits of exercise for preventing and/or managing chemotherapy-induced peripheral neuropathy and related side effects, such as balance impairment and falls(57).”

What the sources say

• Not checked yetcites [57]

In the paper

“There are no randomized controlled trials to date in cancer survivors with falls as a primary endpoint.”

In the paper

“there is very little information regarding the feasibility, safety or benefits of exercise in individuals living with advanced cancer.”

In the paper

“There is insufficient evidence to determine if resistance training alone improves bone outcomes.”

In the paper

“there is insufficient evidence from controlled trials investigating the effect of exercise on sexual function during or after cancer therapy.”

In the paper

“To date most published controlled trials in cancer survivors have examined non-specific pain, and included pain as a secondary outcome, which limits the interpretation of the research.”

In the paper

“Two recent systematic reviews in cancer survivors concluded that across all trials the evidence for exercise to improve bone health is inconsistent(45, 46), though RCTs that were designed with bone health as the primary outcome were largely consistent with the exercise recommendations in the ACSM Position Stand for exercise and bone health(47).”

What the sources say

• Not checked yetcites [47] source

In the paper

“In contrast, aerobic training, particularly walking, does not appear to provide a sufficient stimulus to improve bone outcomes, results that are consistent with RCTs in persons without cancer.”

In the paper

“Two recent systematic reviews in cancer survivors concluded that across all trials the evidence for exercise to improve bone health is inconsistent(45, 46), though RCTs that were designed with bone health as the primary outcome were largely consistent with the exercise recommendations in the ACSM Position Stand for exercise and bone health(47).”

What the sources say

• Not checked yetcites [45] source
• Not checked yetcites [46] source

In the paper

“beyond each outcome, the exercise prescriptions could not be further specified by tumor type, phase of treatment or type of treatment due to the lack of sufficient evidence to do so in a robust manner.”

In the paper

“a further understanding of dose response is limited by a paucity of trials that directly compare two or more levels of exercise training (e.g., high versus low intensity exercise) on cancer-related outcomes(77) or compare settings (e.g., supervised versus home-based)75.”

What the sources say

• Not checked yetcites [77] source

In the paper

“Early promising results for a positive effect of exercise on sexual function among prostate cancer patients treated with androgen deprivation therapy has been reported in some trials(67, 68) but not others(69).”

What the sources say

• Not checked yetcites [67] source
• Not checked yetcites [68] source
• Not checked yetcites [69] source

In the paper

“A recent systematic review of exercise and chemotherapy completion rate concluded that, while promising, the evidence for an exercise benefit to chemotherapy tolerance is insufficient(72).”

What the sources say

• Not checked yetcites [72] source

In the paper

“there is also insufficient evidence at this time for a definitive prescription around safety and efficacy for other types of exercise for cancer survivors, such as dragon boating(79, 80), recreational sports(81), wall/rock climbing(82), triathalon(83), or high intensity interval training(84)”

What the sources say

• Not checked yetcites [79] source
• Not checked yetcites [80] source
• Not checked yetcites [81] source

In the paper

“The 2018 ACSM Roundtable recommendations were made possible due to the increase in the availability of high quality randomized controlled trials of exercise in cancer survivors published after the 2010 recommendations were issued.”

In the paper

“The ACSM pre-participation guidelines do not explicitly address risks for adverse events and/or injury during exercise that are specific to the adverse effects of cancer treatment.”

In the paper

“Based on preliminary evidence(43), the effects seen in breast cancer may not translate for lymphedema following head and neck, bladder, melanoma, gynecologic, or other cancer sites.”

What the sources say

• Not checked yetcites [43] source

In the paper

“In non-cancer populations, whether or not resistance plus impact training programs are safe for individuals with osteoporosis remains controversial(48), thus at this time this exercise prescription may not be safe for cancer survivors with bone fragility associated with osteoporosis or bony metastases in the hip or spine (see section 5).”

What the sources say

• Not checked yetcites [48] source

In the paper

“In non-cancer populations, whether or not resistance plus impact training programs are safe for individuals with osteoporosis remains controversial(48), thus at this time this exercise prescription may not be safe for cancer survivors with bone fragility associated with osteoporosis or bony metastases in the hip or spine (see section 5).”

What the sources say

• Not checked yetcites [48] source

In the paper

“There is a history of clinical recommendations to refrain from aerobic or resistance training in order to avoid onset or exacerbation of lymphedema(33, 34).”

What the sources say

• Not checked yetcites [33] source
• Not checked yetcites [34] source

In the paper

“In non-cancer populations, there is strong evidence that moderate to vigorous intensity aerobic training is associated with better overall sleep quality in the general population(54) and there was some evidence showing benefit for specific characteristics of sleep, such as total sleep time, sleep onset latency, and sleep efficiency.”

What the sources say

• Not checked yetcites [54] source

In the paper

“the significant effects of cancer therapies on hormonal and anatomical/functional changes (i.e., nerve sparing versus non-nerve sparing surgeries in prostate cancer) preclude the ability to extrapolate those findings to the cancer population.”

In the paper

“compelling evidence of a positive effect of exercise on sexual function in the general population, for both women(70) and men(71)”

What the sources say

• Not checked yetcites [70] source
• Not checked yetcites [71] source

In the paper

“Treatment tolerance (i.e., completion of or adherence to planned therapy) is a complex outcome that likely varies by cancer type, treatment modality (i.e., radiation therapy, chemotherapy, hormone therapy, immunotherapy), and even specific drug(s) and protocols.”

In the paper

“a supervised resistance training intervention focused on the upper extremity significantly reduced in shoulder pain in individuals with head and neck cancer(64).”

What the sources say

• Not checked yetcites [64]

In the paper

“While there is compelling evidence of a positive effect of exercise on cognitive function in older adults and other clinical populations(59), specific to cancer, more research is needed in cancer survivors where cognitive function is the primary outcome, and this outcome is assessed by both self-reported and standardized objective measures of cognitive function.”

What the sources say

• Not checked yetcites [59] source

In the paper

“a combined home-based aerobic plus supervised resistance training intervention in women with breast cancer significantly reduced arthralgia associated with aromatase inhibiter therapy(63)”

What the sources say

• Not checked yetcites [63] source

In the paper

“Thus, it remains possible that some proportion of cancer survivors may not be able to tolerate the evidence-based FITT, as explicit reporting of adjustments to the exercise prescription (i.e., dose modification) based on tolerance of individuals has been limited.”

In the paper

“However, given the limited number of rigorously designed studies at that time, there was insufficient evidence to inform specific exercise prescriptions for any of these outcomes nor by cancer site or treatment type.”

What the sources say

• Not checked yetcites [6] source

In the paper

“In addition, studies often did not specifically target enrollment of individuals with the poorest initial values of an outcome (e.g, high fatigue, low bone density) thus the efficacy of a FITT prescription may or may not generalize to cancer survivors in greatest need.”

In the paper

“The addition of resistance training to aerobic training, at least 2 times per week, using at least 2 sets of 8–15 repetitions at least 60% of one repetition maximum, appears to results in similar benefits (BOX 3).”

In the paper

“This allowed for the development of more specific evidence-based exercise prescription to improve common side effects of a cancer diagnosis and treatment, namely anxiety, depressive symptoms, fatigue, health-related quality of life, and physical function, along with safety of exercise training in persons with or at risk of breast-cancer related lymphedema.”

In the paper

“Depending on the nature and extent of a survivor’s presenting problems they may not be able to adequately and/or safely engage in the levels of exercise outlined in this recommendation.”

In the paper

“loss of muscle strength and endurance is common due to deconditioning or as a side effect of cancer treatment.”

In the paper

“There is consistent observational evidence that engaging in physical activity following a cancer diagnosis reduces the risk of cancer-specific and all-cause mortality for individuals diagnosed with early stage breast, colorectal and prostate cancer(104).”

What the sources say

• Not checked yetcites [104] source

In the paper

“an individual’s response to a given exercise stimulus may vary due to the direct effects of cancer treatments on physiological systems (i.e., anemia), side effects of cancer treatment (i.e., cancer-related fatigue may lower exercise tolerance), or demographics factors (i.e., age)(90).”

What the sources say

• Not checked yetcites [90] source

In the paper

“during active treatment an individual’s ability to tolerate exercise may fluctuate from day to day or week to week.”

In the paper

“during chemotherapy treatment there is a well-documented decline in cardiorespiratory fitness, as measured by VO2peak or 6-minute walk test(4).”

What the sources say

• Not checked yetcites [4] source