Schmitz, K. H., Courneya, K. S., Matthews, C., Demark-Wahnefried, W., Galvão, D. A., Pinto, B. M., . . . American College of Sports Medicine. (2010). American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Medicine and Science in Sports and Exercise, 42, 1409–1426.

To synthesize the literature on the safety and efficacy of exercise training during and after cancer treatment and provide guidelines for exercise for patients with and survivors of cancer. Adults with cancer during and after adjuvant cancer treatment were addressed. The guidelines state that the focus is on sites where the most evidence exists:  breast, prostate, colon, hematologic, and gynecologic cancers.

Evaluation of evidence was based on categories from the National Heart, Lung and Blood Institute (A–D levels). Panel member reviews were presented and discussed at the roundtable, and guidelines were developed by consensus. Specific strategy and terms were not described. Guidelines were developed by an expert roundtable in which members were asked to review relevant literature. The guidelines were limited to an adult population and provided an overview of a volume of evidence in multiple outcome areas related to exercise.

A comprehensive and detailed set of guidelines for exercise approaches applicable for survivors of  breast, prostate, colon, hematologic, and gynecologic cancers was provided in the guidelines, as well as some of the issues of exercise training timing related to phases of care. The guidelines also provided a summary of evidence used per cancer site and identified gaps in research because of the small number of studies in some cases and small sample sizes in many of the studies.

Recommendations for exercise testing were as follows:

• Evaluate for peripheral neuropathies, musculoskeletal morbidities, and fracture risk in those who have received hormonal therapies.
• Assess for risks associated with bone metastases and cardiac risks.
• In patients with breast cancer, evaluate arm and shoulder morbidity prior to upper-body exercise.
• In patients with prostate cancer, evaluate muscle strength and wasting.
• In patients with colon cancer, check for infection prevention behaviors for existing ostomy.
• In patients with gynecologic cancers, evaluate for lower-extremity lymphedema prior to vigorous aerobics or resistance; in patients with morbid obesity assess for safety.
• Exercise testing before walking, flexibility, or resistance training is not required.
• In survivors with or at risk for lymphedema, one repetition maximum testing is safe.

Recommendations for exercise prescription were as follows:

• Allow adequate healing time after surgery (may be as much as eight weeks).
• Resolve arm or shoulder problems with patients with breast cancer before upper-body training.
• Swelling or inflammation in gynecology cases should be resolved before exercise training. 
• Patients with ostomies should have doctor permission before contact sports and weight training.
• Changes in symptoms are reasons to stop an exercise program.
• Patients with bone metastases may need to alter exercise intensity, duration, and mode because of fracture risk.
• Specific cancer site–related recommendations are provided for injury prevention and emergencies.

General activity guidelines were as follows:

• Avoid inactivity.
• Aerobic exercise recommendations are the same as general age-appropriate national guidelines.
• Resistance training should be supervised for at least 16 sessions for patients with breast cancer.
• Patients with radical prostatectomy should also perform a pelvic floor exercise with resistance training.
• Resistance training is more important than aerobics for patients who have received transplants.
• Resistance training should be used with caution in patients with lower-limb lymphedema.
• Age-appropriate flexibility training should be followed.
• Ostomies require avoidance of excessive intra-abdominal pressure.
• Research gaps and recommendations were outlined for yoga, sports, Pilates, and other exercises.
   

No participant associations were described.

The guidelines concluded that there was consistent evidence that exercise is safe during and after cancer treatment, with consideration of specific risks that are associated with various types. Exercise training can be expected to improve aerobic fitness, muscular strength, quality of life, and fatigue. Resistance training can be performed safely in patients with and at risk for lymphedema with breast cancer. Some exercise is recommended for all types of patients. Further study is needed in the areas of dose-response effects of exercise training. The guidelines provided additional evidence-based and expert support for the incorporation of various types of exercise in the care of patients with cancer during and after adjuvant treatment. Continued research is needed in this area in terms of research in other cancer types and determination of dose-response relationships for various outcomes.