Friday, October 18, 2019 Roundtable: Exercise Could 'Transform' Cancer Treatment, Prevention A coalition of health and professional organizations led by the American College of Sports Medicine (ACSM) and including APTA is making it clear: physicians, oncologists, policymakers, and all other stakeholders need to recognize that exercise has a crucial role to play in both the prevention of cancer and improving quality of life for individuals who have been diagnosed, and it's time for them to do more to include exercise prescription as a standard of care. Authors of an article recapping the findings and recommendations of the coalition were even more blunt in their assessment, writing that "a drug with a similar benefit profile would likely be prescribed broadly." At the moment, they add, "current practice is failing those with cancer." The article, which appears in CA: A Cancer Journal for Clinicians, is 1 of 3 published after ACSM brought together 17 organizations in 2018 for a roundtable to evaluate the evidence supporting exercise in cancer prevention and treatment recovery, and to develop guidelines and recommendations to foster a stronger embrace of the concept at all levels of health care. Participating organizations included APTA, the American Cancer Society, the National Institutes of Health's National Cancer Institute, the Centers for Disease Control and Prevention, and the American Society of Clinical Oncology, among others. The roundtable was a follow-up to the first such gathering held in 2009. APTA and ACSM established a formal partnership earlier this year. The roundtable's recommendations are bolstered by articles that make the case for exercise as both a cancer preventive and as part of cancer treatment. One of the studies concludes that evidence supports exercise as a way to lower the risk of developing several types of cancer including colon, breast, and lung cancers; a second study establishes a strong link between exercise and improved cancer-related health outcomes such as reduced anxiety, better quality of life, and less fatigue; and the third article summarizes the first 2 and establishes prescription guidelines and a call to action. Taken as a whole, the roundtable and related studies "create a global impact through a unified voice," according to Katie Schmitz, PhD, ACSM's immediate past president and lead author of the summary article. Steve Morris, PT, PhD, president of the APTA Academy of Oncologic Physical Therapy, a coauthor of all 3 studies, and an APTA representative to the roundtable, sees the latest findings and recommendations as a significant step forward. "Much has changed since the findings from the previous roundtable were published," Morris said. "The number of cancers that inactivity has been linked to have increased, and data supporting those links are strong. Also in 2010 there were insufficient data to allow recommending specific exercise prescriptions for either specific cancers or cancer-related health outcomes—that's all changed this time around, and we're providing a care model to the medical community that offers suggestions in how to determine the exercise behavior of an individual and use that information to direct individuals to an exercise program consistent with that patient's reconditioning and medical needs. These new guidelines recognize that all members of the cancer care team can contribute to this effort to get survivors to exercise and exercise safely." Those suggestions encourage oncology clinicians to adopt an "assess, advise, refer" approach with their cancer patients. The clinician first evaluates the patient's current level of physical activity (PA, both aerobic and resistance training) and ability to safely exercise without medical supervision, then advises on the importance of PA and its benefits, and finally refers to an outpatient rehabilitation health professional such as a physical therapist (PT). As for the exercise prescription itself, the coalition found strong evidence to support the health effects of 30 minutes of aerobic activity 3 times a week, and resistance exercises twice a week, structured as 1 exercise per major muscle group, 8-15 repetitions per set, and 2 sets per exercise, progressing in small increments. The CA article makes it clear, however, that oncology clinicians "are not expected to give specifics of exercise prescriptions…or to do extensive screening and triage to determine whether exercise needs to be done in a rehabilitative versus community setting." Instead, authors write, they should approach exercise recommendations much in the way they would approach making recommendations to address a patient's psychosocial distress, making referrals when appropriate. Morris believes the recommendations are easy to use—and, above all, timely. "Given the epidemic of obesity in this country and the strong avoidance of exercise, we have truly a national problem, and turning to the health care community to help manage this problem is certainly reasonable and judicious," Morris said. "The call to action included in these guidelines provides a straightforward way to assess the exercise behavior and hence exercise needs of patients when visiting their physician or other health care provider, and they provide an algorithm that helps health care workers to direct the patient to an exercise program that can safely meet that patient's needs." The summary article includes calls to action for not only oncology clinicians, but also policymakers, researchers, clinical educators, health care providers, the health and fitness industry, and oncology patients and survivors, with authors writing that a shift in thinking and behavior about exercise in cancer treatment "has the potential to transform health and well-being from cancer diagnosis, through treatment, and for the balance of life." Morris sees an opportunity for the physical therapy community to play a major role in shaping that transformation. "We need to advocate supporting physical activity at all levels in public policy discussions," Morris said. "Let's get physical education back in schools. Let's fund community exercise programs. Let's include an exercise prescription or exercise program for every patient at the time they're admitted to our service, and again at discharge. Physical therapists and physical therapist assistants are uniquely qualified to help individuals make some level of physical activity a part of their daily lives no matter their health status, and by doing so, and we can make a difference in the lives of all of our patients, not just cancer survivors." In addition to Morris, APTA members Kristen Campbell, PT, PhD, BSc, and Nicole Stout, PT, PhD, coauthored 1 or more of the roundtable-sponsored studies.