Oncologist Critical in Motivating Cancer Survivors to Exercise

Roxanne Nelson, RN, BSN

February 20, 2018

"Oncologists are critical to the effective promotion and durable uptake of physical activity among survivors of cancer," argue a pair of Australian researchers.

To be effective, physical activity recommendations need to come from the oncologist and to be home based, they argue in a Comments and Controversies  paper published in the Journal of Clinical Oncology (JCO).

Only a minority of cancer survivors are receiving advice from their oncologist about physical activity or are referred to exercise programs as a part of their routine care, note the authors, Sarah Hardcastle, PhD, from the Faculty of Health Sciences at Curtin University, Perth, and University of Western Australia, Crawley, and Paul Cohen, MD, director of gynecological cancer research at St John of God Subiaco Hospital and the University of Western Australia.

For example, a recent study in Canada found that only 19% of oncologists provided specific exercise guidance to at least half of their patients (Support Care Cancer. 2017;25:2297-2304). That same study found that, surprisingly, of a sample of 120 clinicians, 80% did not know about physical activity guidelines for survivors of cancer. (Current guidelines suggest that cancer survivors undertake 30 minutes of moderate activity 5 days a week, the authors note.)

Hardcastle and Cohen argue that oncologists need to be incorporating advice about  physical activity into routine practice.

Oncologists are often perceived by their patients as authority figures, and this puts them in a "unique position to promote the uptake of durable physical activity," the authors comment.

Survivors may be more motivated to change their behavior when the advice comes from their oncologist. This is consistent with findings from several studies that showed patients tended to be more physically active when the exercise recommendation came from their treating oncologist.

"I think more oncologists are becoming aware of the benefits, if only for physical functioning and quality of life and not as much along the lines of cardiovascular risk," Hardcastle told Medscape Medical News. She noted that she has an under-review paper on a survey of 123 oncologists showing that the majority have favorable attitudes toward exercise in survivors.

"I think it's more the case that they are not counseling patients," she explained.

This lack of counseling may be due to several factors. The first is that oncologists might not familiar with the guidelines, and Hardcastle emphasized that this is one reason this paper was written and submitted to JCO: The journal is widely read by oncologists.

Second is a lack of time, a factor that explains why many interactions are brief. If that is the case, patients could be given a written exercise prescription. "If the patient is sufficiently inactive, the oncologist could give him or her a printed exercise prescription — on prescription paper — and a brief rationale concerning the importance of exercise for the prevention of functional decline, and the reduction of fatigue, cardiovascular disease risk, and cancer recurrence, " the authors suggest.

A third reason is that oncologists "do not think patients are interested or that they will be resistant to lifestyle change — and this is a misconception since most patients desire to receive such information and advice and want to receive if from their oncologist," Hardcastle said.

Increasing awareness about the role of physical activity and making it part of standard practice is the difficult part, she noted.

For starters, simple, non–time-consuming interventions must be developed, although much more research is needed on this. "I'm hoping to get a trial off the ground exploring the effectiveness of oncologist-promoted physical activity," Hardcastle explained. "A whole-systems approach, for example, where a nurse or behavior change specialist could implement a more intensive intervention, is likely to be more effective."

"But first we need oncologists on board with a strong message about the importance of exercise post-treatment and an expectation that they will ask about the patient's physical activity at the follow-up appointment," she added.

Type of Exercise Being Promoted

Another issue is the type of physical activity that has been promoted.

Studies to date have almost exclusively focused on facility-based programs and have generally failed to consider "whether this largely sedentary population is sufficiently motivated to take up and maintain a health club membership," the authors write.  

Most of the exercise programs available to survivors generally involve self-referral to facility-based community programs, and although these programs do play a role in promoting physical activity, the uptake and adherence are unlikely to be sustained for any length of time. Barriers to this type of intervention include poor motivation, lack of access (distance, no easy transportation), time, and financial cost. Thus, they write, it is common for these programs to have poor attendance and a high dropout rate.

An alternative is home-based interventions, which offer several advantages. These programs mitigate the problem of distance, access, and transport and are also less expensive than a program that requires participants to attend classes or to maintain a health club membership, the authors point out.

"Furthermore, there seems to be discord between what is available — facility-based programs — and the exercise preferences of survivors of cancer for home-based, unsupervised, moderate-intensity exercise that involves primarily walking," the authors say. If programs are tailored to patient preferences and psychographic profiling, this in turn may optimize adherence and sustainability, they add.

Disagreement From Exercise Researchers

The JCO paper drew criticism, expressed in several letters to the editor.

The strongest attack was in a letter from Scott Adams, PhD, an exercise physiologist from the Memorial Sloan Kettering Cancer Center in New York City, and colleagues, who state that they "fundamentally  disagree" with the opinions expressed.

They take issue with the authors' summation of facility-based exercise program, noting that not only do they disagree that limitations exist (access, motivation, cost) but also that Hardcastle and Cohen have ignored the "pressing issue" of the effective screening and implementation of exercise interventions in cancer.

While patient preference may optimize adherence, that is only one of several factors that must be considered. "Overall, advocating for a simplistic one size, fits all approach, regardless of the setting, cannot possibly address the complex safety, tolerability, and efficacy needs of our patients," they write.

Adams and colleagues also argue that it is unrealistic and overburdening for the oncologist to be the one who screens, designs, and advises/counsels patients on physical activity and exercise. "Moreover, the authors seem to misunderstand the fundamental distinction between the oncologist providing a recommendation for exercise versus the actual physical activity program or exercise prescription," they add.

A second letter to the editor reflected some of the same arguments. Robert Newton, PhD, co-director of the Exercise Medicine Research Institute, School of Medical and Health Sciences at Edith Cowan University, Joondalup, Australia, and colleagues, contend that oncologists "have no training in exercise medicine and cannot realistically prescribe physical activity or exercise."

While they acknowledge that there are financial, accessibility, scalability, and patient preferences to consider, "we do not believe that patients or the oncology professions should settle for a low-fidelity, suboptimal, generic physical activity recommendation," they comment.

In addition, research shows that home-based interventions are far less effective than those undertaken in an exercise clinic under supervision, they add.

Newton et al are also unimpressed with walking as an exercise intervention. They find it "unsurprising" that patients may prefer a walking program, but "they would also prefer to take a placebo pill that has no adverse effects and can be consumed at home rather than having to complete a course of chemotherapy infusions; however, we all acknowledge that it is nonsensical to recommend a treatment that will have no therapeutic benefit just because it is more convenient and bearable."

The third and final letter was less critical and instead focused on the concept of "home-based" exercise. Christian Lopez, from the Faculty of Kinesiology and Physical Education at the University of Toronto, Ontario, Canada, and colleagues, agree with the authors on the importance of developing exercise programs "that are feasible, scalable, and that address issues regarding poor attendance and dropout."

They also agree that home-based exercise interventions may have advantages over those that are facility-based. That said, they note that it is the definition of home-based exercise that "we contend requires cautious interpretation and promotion given the absence of an adequate description and an array of possibilities for home-based exercise available from person to person."

This lack of evidence and clarity, Lopez and colleagues note, is a major challenge when it comes to replicating and implementing home-based programs on a large scale.

The actual settings where a patient may exercise are diverse, and thus the "term independent exercise may be a more appropriate definition for what has traditionally been regarded as home based," they write.

The Authors Respond

In a response to these letters, Hardcastle and Cohen emphasize that they did not say physical activity interventions are the sole domain of the oncologist but simply that oncologists need to be actively involved in promoting physical activity. 

Specifically in response to Adams et al, the authors point out that they do not  "misunderstand the distinction between physical activity recommendations and structured exercise programs…[but that] they are on a continuum of interventions and all play a role, that is, one approach doesn't fit all."

In response to the allegations of Newton et al that "oncologists cannot realistically prescribe physical activity," they point out that research has shown that a verbal exercise recommendation from an oncologist can significantly increase exercise time by 30 minutes a week. Greater increases have been attained when additional motivational strategies have been used.

The authors also responded to the argument raised by both Adams et al and Newton et al that they had failed to acknowledge factors concerning "safety and tolerability." It is precisely for these reasons that lifestyle physical activities are advocated, they argue, such as brisk walking.

"We contend that walking is safe, well tolerated, and the preferred exercise for many survivors of cancer," Hardcastle and Cohen write.

Acknowledging the point made by Newton et al that survivors of cancer "will be older and have numerous comorbidities, which places them at risk when exercising unsupervised," they argue that moderate-intensity physical activity will, in most cases, be safe for this population and may be undertaken independently without supervision.

The authors also emphasize their point that access to facilities is a limitation and cite two studies to support this point. One study found that "268 (20.52%) of 1,306 screened patients were excluded because they lived more than 80 km from the facility," while in the second study, 120 (28.1%) of 427 patients declined participating in an exercise intervention because of distance or lack of transportation.

Hardcastle told Medscape Medical News that it is "very unhelpful that the exercise physiologists are up in arms because we've said that home-based programs are likely to be more effective and certainly more scalable."

"They use issues of 'safety and tolerability' to suggest programs should be supervised and gym-based, but actually most cancer survivors, and especially those who have only had surgery, are no different than age-matched 60-year-old overweight, hypertensive individuals," she said. "For this population, walking is very safe and very tolerable and is the preferred exercise mode by most survivors."

This type of "rhetoric from the physiology world" may just confuse oncologists and cast doubt on the promotion of home-based walking, Hardcastle added.

"Hopefully people will read our reply to their responses and see that their letters are reactive and not grounded in the research literature," she added.

The authors have no disclosures. Some coauthors on the letters have disclosures, as follows: Lee W. Jones (Adams et al) declares stock or other ownership in Exercise By Science; Daniel Santa Mina (Lopez et al) declares honoraria from Sanofi Research Funding and Astellas Pharma, and other relationships with Purdue Pharma; Suzanne K. Chambers (Newton et al) declares serving on the speakers bureau for Tolmar.

J Clin Oncol. 2017;35:3635-3637. Full text

J Clin Oncol. Published online January 26, 2018. Adams et al, Newton et al, Lopez et al, Hardcastle and Cohen

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