the role and efficacy of exercise in persons with cancer
TRANSCRIPT
Theme Issue: Exercise and Sports
The Role and Efficacy of Exercise in Persons WithCancerSarah M. Eickmeyer, MD, Gail L. Gamble, MD, Samman Shahpar, MD,
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Abstract: Improvements in cancer screening, diagnosis, and treatment have resuincreasing population of cancer survivors with impairments in physical functionrelated symptoms, and reduced quality of life. Exercise and physical activity have ttic value at multiple points along the cancer disease continuum, spanning diseasetion, treatment, survivorship, prognostic outcomes, and end-of-life issues. Mmechanisms for the influence of exercise in persons with cancer include alterininitiation pathways and affecting hormonal, inflammatory, immune, and insulin pPhysical activity has been found to play a role in the prevention of certain maliincluding breast, colon, and other cancers. An increasing amount of evidence indicphysical activity may affect prognostic outcomes in certain cancer diagnoses, ebreast cancer. Structured exercise and physical activity interventions can be haddressing specific survivorship issues, including overall quality of life, cardioreimpairment, cancer-related fatigue, and lymphedema. Exercise also may be helpfuthe palliative care phase to alleviate symptoms and increase physical well-being. Thwill familiarize physiatrists with the current state of evidence regarding the role andof exercise in persons with cancer.
PM R 2012;4
INTRODUCTION
Since antiquity, physical exercise has been recognized as providing health benefitsthe middle of the 20th century, however, did large, well-controlled epidemiologidocument that physical exercise provides protection from myocardial infarctiondiovascular disease. It has only been in recent decades that further scientific evidaccumulated to better define and expand the health benefits of physical exercise wito the skeletal, neuromuscular, endocrine, and immune systems and in alleviatingfrom various disease states, including obesity, diabetes mellitus, osteoporosis, deand insomnia. The multiple roles that exercise plays in mediating cancer devetreatment, and outcomes are now being more comprehensively examined and undfollowing in the footsteps of the other global health risk that has escalated inexorabthe past 50 years, namely, cardiovascular disease.
Improvements in cancer screening, earlier detection and diagnosis, treatmvancement, and improved survival have resulted in an increasing cancer survpopulation that is now estimated at more than 13 million [1]. In recentincreased interest has been shown in defining the issues of survivorship, ichanges in physical strength, fatigue, quality of life (QOL), and physical functin documenting the positive effects of exercise interventions and physical acaddressing these problems [2-4]. To increase awareness of the safety and efexercise and physical activity through survivorship across the spectrum o(Figure 1), the American College of Sports Medicine published its Exercise Gufor Cancer Survivors in 2010 (Table 1) [5].
Cancer and its treatment can decrease physical function and independence aspectrum of disease [6,7]. In a recent article, Huang and Sliwa [8] reviewed patie
cancer within the inpatient rehabilitation setting. Without reference to specific exePM&R © 2012 by the American Ac1934-1482/12/$36.00
Printed in U.S.A.874
ilityion,ent,
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S.M.E. Department of Physicaand Rehabilitation at the MedicaWisconsin and Clement J. Zabloical Center, Milwaukee, WI. Adspondence to S.M.E., Clement J.Medical Center, 5000 W. NatioPM&R 117x Milwaukee, WI [email protected]: nothing to disclose
G.L.G. Department of Physical MRehabilitation at Northwestern Unberg School of Medicine, and thtion Institute of Chicago, ChicagoDisclosure: nothing to disclose
S.S. Department of Physical MRehabilitation at Northwestern Unberg School of Medicine, and thtion Institute of Chicago, ChicagoDisclosure: nothing to disclose
K.D.D. Department of Physical MRehabilitation at the University of
rcisewestern Medical Center, Dallas, TXDisclosure: nothing to disclose
ademy of Physical Medicine and RehabilitationVol. 4, 874-881, November 2012
http://dx.doi.org/10.1016/j.pmrj.2012.09.588
nt fuorts wutpaticapacvel. Wstudieerm cts infunct
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875PM&R Vol. 4, Iss. 11, 2012
intervention, patients with cancer made significational gains that were similar to those of their cohdid not have cancer. Van Weert et al [9] found that orehabilitation exercise programs improved aerobicfatigue, and physical function on a meta-analysis leregard to home-based therapies, Morey et al [10]home-based exercise and diet intervention in long-tcer survivors and found that the QOL of patientreatment group improved and that they maintainedto a higher degree compared with control patients.
Diagnosis Cancer Control Categorie
T t t Treatment R /
SurvivorshipTreatmentPre-TreatmentScreeningPrevention
Prevention DetectionTreatment
Preparation/Coping
TreatmentEffectiveness/
Coping
Recover/Rehabilitation Pal
Disease Prevention/Health Promotion
sisongaiD-tsoPsisongaiD-erP
Cancer-Related Time Periods
Figure 1. The spectrum of cancer disease, diagntreatment with key periods for rehabilitation inte(Reprinted from Courneya KS, Friedenreich CM. Physiity and cancer control. Semin Oncol Nurs 2007;23Copyright 2007 Elsevier.).
Table 1. Summary of the American College of Spor
Aerobic
U.S. Physical Activity Guidelinesfor Americans (PAGA)†
150 min/week ofmoderate-intensit75 min/week ofvigorous-intensityactivity or anequivalent comb
Breast Follow U.S. PAGA
Prostate Follow U.S. PAGAColon Follow U.S. PAGA
Gynecologic Morbidly obese womay require addisupervision
Hematologic, no HSCT Follow U.S. PAGAHematologic with HSCT Recommended sta
with lighter intensand slower progreto greater intensitduration
ACSM � American College of Sports Medicine; HSCT � humanCourneya KS, Schmitz KH. Implementing the exercise guidelines*Adapted from Schmitz et al [5].
†Physical Activity Guidelines Advisory Committee [49].nc-hoentity,ithd aan-theion
Efforts to study the effects of exercise andactivity in recent years have been limited by sigvariability in study format. Studies often do nottiate between structured exercise and physical acdescribed interventions, which makes the compamultiple studies difficult. To better understand amote evidence in this area, it is useful to delineaterms. Physical activity has been described as amovement requiring energy expenditure; it caactivity of daily life or recreational. Exercise also isas movement but is more structured and has meparameters, including body fat, range of motionstrength, endurance, and cardiovascular capaciLooking at both types of activity is important inbecause we treat many patients for whom a stexercise intervention may not be feasible yet wbenefit from effects of a physical activity interThroughout this article we are referencing structercise interventions, unless otherwise indicated.
The purpose of this article is to (1) raise awarenevalue of exercise for patients with cancer, not onltients with cardiovascular and other chronic healt(2) present a clinical disease trajectory highlightingof exercise at multiple points of the continuum; (3) pmolecular rationale for the success of exercise in botprevention and disease deterrence; (4) share spedence-based clinical data for exercise success in
vival
ndns.tiv-52.
icine Exercise Guidelines for Cancer Survivors�
Resistance Flexibility
Muscle-strengthening activities ofat least moderate intensity atleast 2 days/week for eachmajor muscle group
Stretch major muscleand tendons on dayactivites are perform
Start with supervised program andprogress slowly
Follow U.S. PAGA
Follow U.S. PAGA Follow U.S. PAGAFollow U.S. PAGA except withstoma, where lower resistanceand slower progression arerecommended to avoidherniation
Follow U.S. PAGA, takto avoid excess abdpressure if patient haostomy
Data on safety and benefits arenot available for women withlower limb lymphedema
Follow U.S. PAGA
Follow U.S. PAGA Follow U.S. PAGAFollow U.S. PAGA; resistancetraining may have particularbenefits in this population
Follow U.S. PAGA
cell transplant. Reprinted with permission from Wolin KY, Schwartz AL, Macer survivors. J Support Oncol 2012;10:171-177. Copyright Elsevier.
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876 Eickmeyer et al CANCER AND THE ROLE AND EFFICACY OF EXERCISE
outcomes of specific cancers; and (5) present anbase for exercise amelioration of specific survivorshincluding overall QOL, cardiorespiratory impairmcer-related fatigue, and lymphedema.
EXERCISE: MOLECULAR MECHANISMS
The molecular mechanisms that underpin the bexercise in humans in terms of overall health, longefreedom from disease are likely to share commonoverlapping benefits that mediate improved outcspecific organ systems and diseases, especially cardiodiseases and cancer. On the basis of these general pemerging investigations have delineated biochemmolecular pathways that can be modulated favoexercise. Favorable benefits of exercise on cancer prand the efficacy of oncologic therapies have been invmost intensively in various epidemiologic studies antrials. Recently, investigations have been undertakvestigate the specific benefits of exercise in cancership and the role of exercise in the palliative care o
Figure 2. Multistage carcinogenesis: processes andstrategies is shown. The initiation stage is characteDNA-damaging agents, with the genetic damage inof an initiated cell into a population of preneoplasticprogression stage is characterized by the transformaadditional genetic alterations (indicated by additiindicated by brick walls along the pathway. ROS �al. Mechanism-based cancer prevention approach1999;91:215-225. Copyright 1999 Oxford University Pre
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The multistep pathways mediating carcinogenebeen defined and further refined during the pasdecades. More recent work has been focused on thcancer cells that can be defined as tumor stem celtumor stem cells function as initiated cells that tranpreneoplastic cells and eventually convert to bonaplastic, malignant cells, giving rise to the primary tupotential metastatic generations of cells. Specific svia exercise that have been identified to target initiapromotion-progression are highlighted in FigureCancer prevention through exercise has been showspecific pathways of tumor initiation/carcinogenesidition, exercise may exert a cancer preventive effect bening the processes involved in the promotion andsion of malignancy, including increased efficiency treactive oxygen species (ROS); exerting regulatiocontrol of cell replication; enhancing efficiency ofapoptosis; and differentiating and modulating pro-intory pathways that enhance carcinogenesis. Further,exercise has the ability to stimulate innate immune r
ntion strategies. A schematic presentation of stage-specific pry the conversion of a normal cell to an initiated cell in resd by an X. The promotion stage is characterized by the transf
as the result of alterations in gene expression and cell proliferaf the preneoplastic cells to a neoplastic cell population as as). Intervention points for strategies to prevent these procee oxygen species. (Reprinted from Hursting SD, Slaga TJ, Fischrgets, examples, and the use of transgenic mice. J Natl Cad with permission.)
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877PM&R Vol. 4, Iss. 11, 2012
Hormonal mechanisms of cancer prevention hproposed on the basis of epidemiological studies, suthat exercise may reduce levels of ovarian hormonerisk of developing breast, endometrial, and ovarian[13]. Similarly, exercise is recognized to promotebody weight and decrease insulin resistance, which man indirect effect on reducing the risk of developingrelated cancers, such as colon, breast, and endomecers [13,14].
Growing evidence exists that similar or linked psuch as those mediating tumor inflammation and geof ROS, also may be important for controlling tumosiveness and response to oncologic therapies. Thpathways operate not only in cancer prevention butexert activities to extend the time to cancer progresprevent relapse, as well as promote overall cancership. Physical activity and defined exercise interhave been shown to favorably affect these pathwaymals, and developing research has documented thethese pathways in human cancer as well. Severaarticles of epidemiologic studies highlight hypothphysical activity may affect the insulin, inflammimmune pathways, thus improving overall survivalease-free intervals after breast and colon cancerSeveral studies report greater benefit of physicaamong women with hormone receptor–positive bmors, suggesting a possible hormonal mechanism [
EXERCISE AND CANCER OUTCOMES
Cancer Prevention
The role of physical activity in cancer preventionwell studied in the clinical literature, especially fand breast cancers. The American Cancer Sociepublishes guidelines on nutrition and physical accancer prevention every 5 years, with the mosupdate in 2012 [14]. The ACS cites evidence thaphysical activity may reduce the risk for breast, colometrial, and advanced prostate cancer and possiblyatic cancer [14].
Recent review articles reiterate the protectiveregular physical activity on the prevention of cancdenreich et al [13] published a review of epideevidence for physical activity and cancer preventlevel of evidence for risk reduction with physical actconvincing for colon cancer, probable for breast anmetrial cancers, and possible for ovarian, lung, andcancers. Risk reduction with physical activity rang10%-30% for these 6 cancer types. These investigaestimated that between 165,000 and 330,000 cases ocancers could have been prevented over 1 year inalone if the population had maintained sufficient
physical activity. A review by Wiggins and Simonavice [1eningtheersthyvety-an-
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also found strong evidence that physical activity redrisk of colon and breast cancer, with less evidence fmetrial, prostate, and lung cancer. Anzuini et al [18]strong evidence that physical activity in animal mduced the risk of breast and colon cancer. They alevidence that leisure-time physical activity reducedof colon cancer, postmenopausal breast cancer, aprostate cancer, endometrial cancer in overweightand lung cancer in smokers in a review of human s
The ACS recommends at least 150 minutes of mintensity activity or 75 minutes of vigorous-intensita week to see a protective benefit [13,14], which is cwith the American College of Sports Medicine exercilines for cancer survivors (Table 1) [5]. These guidereview articles do not distinguish between physicaand exercise; rather, they suggest moderate- to vintensity activity to see a protective effect. Friedenr[13] noted a dose-response effect, with increasingvigorous activity providing more protection frombreast, and endometrial cancers.
Cancer Prognosis: Survival andDisease-Free Interval
Historically, the overall survival rates after cancer thave been the most common outcome reported in tlogic literature. However, the importance of the disinterval after cancer treatment is increasingly reposhould be stressed in the rehabilitation literature. Afree interval can be defined as the time to recurreinitial cancer treatment. It is during this period thatwith cancer often are seen by physiatrists to maximical function and QOL. Both overall survival and thefree interval commonly are used as end points in clinfor cancer treatment. The role of physical activity ining overall survival and extending disease-free intwell established in persons with breast and colon cais showing promise in ongoing studies of lung, bratate, and gynecologic cancer.
The most frequently published studies in the lregarding the role of physical activity and prognoto breast cancer. In a landmark self-report study bresponses from the Nurses’ Health Study, wombreast cancer who engaged in regular physicalafter diagnosis had prolonged overall survival andfree intervals, with the greatest benefit noted inwho performed 9 to 14.9 metabolic equivalenthours per week of physical activity, correlating to3 to 5 hours a week [19]. Even patients who waMET-hours per week, or �1 hour a week of walka protective effect. This association was strongeswomen with hormone-responsive tumors, suggpossible hormonal mechanism. Leisure-time phy
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878 Eickmeyer et al CANCER AND THE ROLE AND EFFICACY OF EXERCISE
assigned MET score, and the hours per week spenactivity, to calculate a MET-hours per week score.review by McTiernan et al [15] found a protectivephysical activity and improved overall survivalcancer in several large cohort studies. Ballard-Barb[17] reviewed 17 observational studies of patiebreast cancer and found that physical activity watently associated with a reduction in breast cancerand all-cause mortality, with some evidence sugdose-response effect of increasing risk reductiincreasing activity levels.
The role of physical activity and prognosis in paticolon cancer also has a well-established literature brecent review by Denlinger and Engstrom [16],activity was shown to decrease colon cancer recurrand mortality in several large cohort studies. Thesoverall found that higher levels of activity—at leasthours per week—may be required in persons wicancer compared with persons with breast cancebeneficial effect on prognostic endpoints. Ballard-Bal [17] reviewed 6 cohort studies of physical acpersons with colon cancer and found a consistent rin colon cancer–specific and all-cause mortality, wevidence suggesting a dose-response relationship.
Promising studies show a possible associationphysical activity and prognosis in lung, brain, prosgynecologic cancer populations. A prospective cohof patients with metastatic lung cancer found that fucapacity, as assessed by a 6-minute walk test, waspendent predictor of overall survival [20]. In additients reporting �9 MET-hours per week of exerprolonged survival compared with patients who repMET-hours per week—26 versus 13 months, respesimilar prospective cohort study of patients withmalignant glioma found that �9 MET-hours perexercise was associated with a median survival of 22whereas �9 MET-hours per week was associatemedian survival of 13 months [21]. A large cohortpatients with prostate cancer found that increasedphysical activity were associated with a reduction inand prostate-specific mortality [22]. In a review artTiernan et al [15] found evidence that obesity was awith decreased overall survival in persons with endand ovarian cancers. It is hoped that future stuelucidate these relationships further.
EXERCISE AND ISSUES OF CANCERSURVIVORSHIP
Quality of Life
QOL encompasses physical, psychological, social, atual aspects of well-being. With improvements in
rates, patients with cancer are more likely than ever to exhatentof
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rience the detrimental effects of both the diseasetreatments, often affecting their own QOL. It is impothe rehabilitation practitioner to know that both exephysical activity are reported to improve QOL botand after treatment.
In a comprehensive review, Speed-Andrews anneya [23] found a consistent positive associationphysical activity and improved QOL during treatbreast cancer, prostate cancer, and hematologic mcies, as well as beneficial effects on other measuresmood and fatigue. Recently, in several large rancontrolled trials, investigators also have reported thof structured exercise interventions during cancer trincluding the Supervised Trial of Aerobic versus RTraining (START) for patients with breast cancer wreceiving adjuvant chemotherapy [24], the Healthyfor Lymphoma Patients (HELP) trial for adult patielymphoma who were receiving chemotherapy [25randomized controlled trial in which investigators cresistance or aerobic exercise in patients with prostawho were receiving radiation therapy [26]. Eachtrials reported improved QOL among other meamood, fitness, and physical function.
The prolonged survivorship phase after cancer talso has been targeted for exercise and physicalinterventions. Speed-Andrews and Courneya [23] ala consistent positive association between QOL andactivity interventions during the prolonged phase acer treatment. Again, the reviewed studies focusedinantly on breast cancer survivors. Morey et al [10] shome-based exercise intervention in long-term cobreast, and prostate cancer survivors (those wholonger than 5 years), and found that patients’ QOL immore in the treatment group compared with controlat 1-year follow-up. In a meta-analysis, van Weertfound that low- to moderate-intensity exercise pimproved cancer survivors’ sense of physical well-bQOL, whereas high-intensity exercise programs imphysical function but not necessarily QOL.
Cancer-Related Fatigue
The National Comprehensive Cancer Network deficer-related fatigue (CRF) as a distressing persistenttive sense of physical, emotional, and/or cognitiveor exhaustion related to cancer or cancer treatment tproportional to recent activity and interferes with ustioning [27]. CRF is one of the most common and cosymptoms for patients throughout the spectrum of odiagnoses, not only during the active phases of treatmoften persisting among disease-free survivors [28-3multifaceted condition with contributing etiologiesing anemia, nutritional deficiencies, endocrine dysf
pe- cardiopulmonary dysfunction, mood disturbance, pain,
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879PM&R Vol. 4, Iss. 11, 2012
sleep disturbance, deconditioning, treatment-relateand the underlying malignancy.
Beyond addressing the underlying treatable factsensus is lacking regarding the best interventions forwith CRF. However, as discussed elsewhere, exebeen shown to have positive effects on many factorsuting to CRF, including muscle strength, cardiopufitness, aerobic capacity, quality of sleep, pain, andisturbances. In 2008, 32 patients with cancer whoto severe fatigue during and after chemotherapyrolled in a 3-week aerobic and resistance trainingand demonstrated a 25% reduction in global fatigucomprehensive review of exercise interventions inwith CRF found benefit during and after cancer treapatients with breast cancer or solid tumors and inundergoing hematopoietic stem cell transplantathough the beneficial effects were not consistent acries, which included significant variability of inter[32]. Although promising, these results often are dtranslate clinically because of the variability in tpopulations, as well as exercise type, duration, frintensity, and degree of supervision. More focused reneeded to better appreciate the multiple domains tthis condition, and, with this knowledge, to devimplement specific but comparable exercise intervemitigate overall fatigue in the cancer population.
Cardiopulmonary Fitness
Cardiopulmonary fitness as measured by peak oxysumption (VO2peak � mL·kg�1·min�1, 3.5 mL·kg�1·1 metabolic equivalent/MET) is a known key predmortality in all populations. Previous research dema 12% improvement in survival for men and a reddeath by 17% in women for every 1 MET increase icapacity [33,34]. This information holds even mortance for patients with cancer. For example, in thcancer population, it has been shown that VO2pea
lower than age-matched healthy sedentary women [vious studies have demonstrated improvements inpulmonary fitness with structured exercise intervepatients with cancer. However, small sample sizesability among interventions and outcome measumade clinical application difficult. Jones et al [36] pa meta-analysis on VO2peak in patients with non-Hlymphoma, breast cancer, prostate cancer, and colowho participated in randomized trials of structuredinterventions. Not only did the results indicate that mintensity exercise was associated with improvemVO2peak, but the control group, who did not participate itraining, was noted to have a significant decrease in[36]. Although limited by the heterogeneity amongies, given the known relationship between VO2peak
tality, the results should not be underestimated. As m
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information is gained about cancer diagnoses alongtrum of care, we must develop best practice and ebased guidelines for exercise prescriptions, accounindividualizing for population-, cancer-, and patientfactors.
Cancer-Related Lymphedema
Cancer-related lymphedema remains a major consurvivors of breast, gynecologic, and other cancersthe lymphatic system. Because of the fear of develexacerbating lymphedema, survivors often minimcise, which not only may impede their recovery butlead to overall activity avoidance [37,38]. To addrfears, authors of the Physical Activity and Lymp(PAL) trial evaluated 154 breast cancer survivors aonstrated that a supervised program of slowly proweight lifting compared with no exercise did notan increased incidence of lymphedema, wheweight-lifting group improved strength and lowebody fat percentage at 12-month follow-up. Althoa primary outcome of the PAL trial, the findings suthat a weight-lifting program may reduce the incilymphedema in at-risk patients [39]. Althoughspecifically focused on a weight-lifting program,cise program also should include flexibility, strand aerobic exercise. Aerobic and resistance exercbeen demonstrated to be safe for patients with breawho are at risk for lymphedema, and they have beeto preserve VO2peak and improve self-esteem [24].rent clinical consensus exists about whether to use csion consistently during exercise of the area at risk.ous study, however, has demonstrated that exerciseffective in enhancing lymph flow and improvingresorption while the affected area is bandaged orwith a well-fitting compression garment, augmeneffect of muscle contractions on the lymphatic fluid [key to developing a successful exercise interventionindividualize the program based on the location andthe lymphedema, to understand premorbid activity tand capabilities, and to accommodate any comorbidprecautions.
Exercise and Palliative Care
Palliative care and rehabilitation medicine sharefeatures. Palliative care is not synonymous with encare, but like rehabilitation medicine, it focuses otom management in patients with advanced, dconditions. Both specialties function in interdiscteams, and both highly value QOL issues. Forwith advanced cancer, it is clear that the ability toindependent, to do what one wants, and to be ph
ore strong is of high importance [41,42].
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880 Eickmeyer et al CANCER AND THE ROLE AND EFFICACY OF EXERCISE
Although limited, a growing number of studiespositive effect for exercise interventions for patiecancer who receive palliative care [43,44]. In anintervention for 34 patients receiving palliativehospice care, a physical therapist led a structured 5program, followed by specific physical performancemeasures, including the 6-minute walk, timed sit-and functional reach. Subjects had a significant imprin walking distance, a significant decrease in timestand, and some nonsignificant improvement in reticipants also showed significant improvement infor emotional function and improvement in fatigu[45]. In 2 different qualitative studies capturingreactions to physical therapy in the palliative carepatients consistently commented that physical thimportant and that being guided by a skilled physicpist gave comfort. Participation in the therapy procreased daily routine capability, provided structurefered hope [46,47]. In the current era in whichincreasingly is acknowledged as a valuable asset icare treatment and prevention, further controlled stgreatly needed to substantiate the value of structusupervised exercise for the often more debilitatedreceiving cancer-related palliative care.
SUMMARY
As the cancer survivor population continues to grobilitation providers increasingly will be exposed to isinfluence survivors’ physical function, QOL, andspecific impairments. Evidence supporting the inflexercise and physical activity on cancer outcomes ishighlighting the need to implement exercise guidelincancer survivors [5,48]. As stated previously, moclinical literature focuses mainly on exercise for breasurvivors, and future studies must be designed toother tumor types. Physiatrists and other exercise prals play a key role in developing safe and effectiveprograms for survivors, including pre-exercise evalucardiopulmonary fitness, musculoskeletal comoand the role of treatment adverse effects such as chapy-induced peripheral neuropathies, hormonerelated osteoporosis, and breast cancer surgershoulder morbidity [48]. With improved awarenerole of exercise along the cancer disease continuumitation providers can use an evidence base to partneroncology community to develop critically neededprescriptions and programs.
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