Expert discusses making exercise part of routine cancer care
While most oncologists would agree that exercise is important for people with cancer, generic guidelines for this population do not address the high need for personalized exercises.
Daniel Santa Mina, assistant professor in the Faculty of Kinesiology & Physical Education, recently shared with The Lancet Oncology journal a clinical tool that he and his colleagues at Princess Margaret Hospital developed to respond to the high demand for exercise services by oncology patients and clinicians.
The Safety Reference Guide essentially provides an "If yes, then" tool. For example, if a patient has high blood pressure, the guide directs clinicians on whether medical clearance is necessary and how to adapt exercise for specific signs and symptoms that might increase exercise risk.
"It was important for us to develop some guidance around how to approach common clinical signs and symptoms that increase exercise risk," says Santa Mina. "As a trainee and even as a professional, I am used to turning to standard texts in exercise sciences that describe what to do when you have a client with a specific condition – for example, high blood pressure, high resting heart rate or a specific type of injury.
"These guidelines typically say, if the client has a particular condition, they shouldn't exercise or they need clearance from a medical doctor to exercise. But, these can be barriers because a) they may require patients to get clearance from a medical doctor and b) medical doctors don't always know what is safe."
One issue, according to Santa Mina, is that people with cancer have a lot of accompanying conditions (due to the disease, its treatment, or other health complications), so they end up not exercising. The other problem is that sometimes the people who are testing/training them don't know what to do when faced with one or a variety of these scenarios.
"Our guide says that when 'x' appears, this is what we do. It's based on the best available evidence from oncology, but other populations as well, because we don't have specific data on oncology patients for everything," says Santa Mina.
"While this is a limitation, we need to do something when these patients arrive at our program doors, and our guide provides a practical and systematic approach for various signs and symptoms where other guidelines just don't apply well in oncology."
What makes the guidelines unique in comparison to the well-cited and highly visible generic guidelines for exercise is that they add a plan when a specific scenario shows up, says Santa Mina. For example, if a patient has low blood counts of a particular nature, it says to adapt the exercise with specific precautions or seek medical clearance, depending on how 'off' the values are from normal. They also provide more 'grace' in terms of risk screening for exercising cancer patients because if conventional thresholds were applied, a lot of the patients would be excluded.
Santa Mina points out that the guide is the result of an interprofessional collaboration with expertise in physiatry (MD), internal medicine / geriatrics, cardiac rehab, physiotherapy, kinesiology, palliative care and psychosocial oncology. Furthermore, it is applied in a cancer centre where it can be applied by those qualified to assess and respond to the scenarios described, and thus it may not be representative of what other programs may use to screen, assess risk, and adapt exercise for people with cancer.
But Santa Mina is keen to encourage professionals to consider the breadth of evidence in clinical exercise physiology to make informed decisions on how to provide exercise to people with cancer given the benefits.
"Exercise safety in oncology has historically been vague and we have exercised patients with such conservative approaches that may have limited its effects with suboptimal doses, or excluded those patients that may need it most from exercise altogether," says Santa Mina.
"Critics will highlight that there isn't established evidence for each decision point, but my counterargument is that withholding an important and proven part of therapy in cancer care because there isn't a perfect data set is not an appropriate response to patients and clinicians looking for exercise. We need to try to support exercise-related needs with clinical judgment and the best available evidence.
"Exercise is adaptable and the guide is intended to evolve and adapt as new evidence emerges."