Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer.

Multiple organizations around the world have issued evidence-based exercise guidance for patients with cancer and cancer survivors. Recently, the American College of Sports Medicine has updated its exercise guidance for cancer prevention as well as for the prevention and treatment of a variety of cancer health-related outcomes (eg, fatigue, anxiety, depression, function, and quality of life). Despite these guidelines, the majority of people living with and beyond cancer are not regularly physically active. Among the reasons for this is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. The authors propose using the American College of Sports Medicine's Exercise Is Medicine initiative to address this practice gap. The simple proposal is for clinicians to assess, advise, and refer patients to either home-based or community-based exercise or for further evaluation and intervention in outpatient rehabilitation. To do this will require care coordination with appropriate professionals as well as change in the behaviors of clinicians, patients, and those who deliver the rehabilitation and exercise programming. Behavior change is one of many challenges to enacting the proposed practice changes. Other implementation challenges include capacity for triage and referral, the need for a program registry, costs and compensation, and workforce development. In conclusion, there is a call to action for key stakeholders to create the infrastructure and cultural adaptations needed so that all people living with and beyond cancer can be as active as is possible for them.

Moving through cancer: Setting the agenda to make exercise standard in oncology practice.

LAY SUMMARY: International evidence-based guidelines support the prescription of exercise for all individuals living with and beyond cancer. This article describes the agenda of the newly formed Moving Through Cancer initiative, which has a primary objective of making exercise standard practice in oncology by 2029.

Characterization and Management of Hedgehog Pathway Inhibitor-Related Adverse Events in Patients With Advanced Basal Cell Carcinoma.

Abnormal activation of hedgehog pathway signaling is a key driver in the pathogenesis of basal cell carcinoma (BCC). Vismodegib, a first-in-class small-molecule inhibitor of hedgehog pathway signaling, is approved by regulatory authorities for the treatment of adults who have metastatic BCC or locally advanced BCC that has recurred after surgery, or who are not candidates for surgery and who are not candidates for radiation. A second inhibitor, sonidegib, was also recently approved for the same patient group with locally advanced BCC. Adverse events (AEs) commonly observed in hedgehog pathway inhibitor (HPI)-treated patients include muscle spasms, ageusia/dysgeusia, alopecia, weight loss, and asthenia (fatigue). These AEs are thought to be mechanistically related to inhibition of the hedgehog pathway in normal tissue. Although the severity of the majority of AEs associated with HPIs is grade 1-2, the long-term nature of these AEs can lead to decreased quality of life, treatment interruption, and in some cases discontinuation, all of which might affect clinical outcome. The incidence, clinical presentation, putative mechanisms, and management strategies for AEs related to HPIs in advanced BCC are described. These observations represent the first step toward the development of mechanism-based preventive and management strategies. Knowledge of these AEs will allow health care professionals to provide appropriate counseling and supportive care interventions, all of which will contribute to improved quality of life and optimal benefit from therapy. IMPLICATIONS FOR PRACTICE: The hedgehog pathway inhibitors (HPIs) vismodegib and sonidegib represent a therapeutic breakthrough for patients with advanced basal cell carcinoma. However, the nature of the low-grade adverse events (AEs) commonly observed in HPI-treated patients, including muscle spasms, ageusia/dysgeusia, alopecia, weight loss, and fatigue, can impact clinical outcomes as a result of decreased quality of life and treatment discontinuation. The incidence, clinical presentation, putative mechanisms, and management strategies for AEs related to administration of HPIs are described, with the goal of enabling health care professionals to provide appropriate counseling and supportive care interventions to their patients.

Medical and Cardiac Risk Stratification and Exercise Prescription in Persons With Cancer.

ABSTRACT: Cancer patients are recommended to exercise at all stages of disease given the multiple health and functional benefits of physical activity. Certain safety precautions, including a preparticipation medical evaluation and periodic re-evaluations, should be undertaken before creating an exercise program based on individual cancer and treatment history. When designing an exercise program, physiatrists should use similar principles of frequency, intensity, timing, and type for cancer patients that are used for noncancer patients. Special attention to risks of cardiac and pulmonary disease along with risks of sarcopenia, thrombocytopenia, anemia, neutropenia, fracture risk, neurotoxicity, lymphedema, and metastases should be made. This article will outline these specific risks and necessary modifications to the exercise prescription for cancer patients that can be used to enable safe participation in recommended exercise.

Translating 2019 ACSM Cancer Exercise Recommendations for a Physiatric Practice: Derived Recommendations from an International Expert Panel.

In 2018, the American College of Sports Medicine (ACSM) reconvened an international, multi-disciplinary group of professionals to review pertinent published literature on exercise for people with cancer. The 2018 roundtable resulted in the publication of three articles in 2019. The three articles serve as an important update to the original ACSM Roundtable on Cancer, which convened in 2010. Although the focus of the three 2019 articles is on exercise, which is only one part of comprehensive cancer rehabilitation, the evidence presented in the 2019 ACSM articles has direct implications for physiatrists and other rehabilitation professionals who care for people with cancer. As such, the narrative review presented here has two primary objectives. First, we summarize the evidence within the three ACSM articles and interpret it within a familiar rehabilitation framework, namely the Dietz model of Cancer Rehabilitation, in order to facilitate implementation broadly within rehabilitation practice. Second, via expert consensus, we have tabulated relevant exercise recommendations for specific cancer populations at different points in the cancer care continuum and translated them into text, tables, and figures for ease of reference. Notably, the authors of this article are members of the Cancer Rehabilitation Physician Consortium (CRPC), a group of physicians who subspecialize in cancer rehabilitation medicine (CRM).

The effect of preoperative exercise on upper extremity recovery following breast cancer surgery: a systematic review.

Prehabilitation benefits among patients undergoing various oncological surgeries have been demonstrated. However, the effects of presurgical exercise and fitness on postoperative ipsilateral upper extremity recovery outcomes in patients with breast cancer surgery are less evident. A systematic review was performed to assess the effects of preoperative exercise and fitness on postmastectomy recovery. Systematic literature search was performed in 12 electronic databases. Study eligibility was accessed using the PICOS (Participants, Interventions, Comparison, Outcome and Study Design) criteria. Six eligible studies were found: three cohort-control and three prospective observational studies. One randomized-controlled trial showed that prehabilitation was beneficial in shoulder range of motion (ROM) and upper extremity functional recovery. One cohort-control study demonstrated that preoperative exercises reduced postoperative pain without increasing the risk of developing a seroma. A prospective cohort study showed that preoperatively active individuals had a significantly better chance of feeling recovered physically at 3 weeks after surgery. Baseline ipsilateral grip strength, shoulder flexion, and abduction ROM were reliable predictors of shoulder flexion and abduction ROM and grip strength improvements at 1 month following breast cancer surgery. One study showed that preoperative conditioning alone without postoperative rehabilitation was insufficient to aid recovery. Implementing exercise program and optimizing preoperative fitness, especially shoulder ROM, before breast cancer surgery in conjunction with individualized rehabilitation program may benefit postmastectomy ipsilateral upper extremity recovery.

Prolotherapy versus corticosteroid injections for the treatment of lateral epicondylosis: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of prolotherapy versus corticosteroid injection for the treatment of chronic lateral epicondylosis. DESIGN: A prospective, randomized controlled, double-blinded study. SETTING: Academic, tertiary, outpatient, rehabilitation hospital. PARTICIPANTS: Twenty-four subjects with clinically determined chronic (ie, lasting 3 months or longer) lateral epicondylosis were recruited. All subjects noted pain intensity levels significant enough to prevent the participation in activities, such as playing racquet sports or lifting heavy objects. METHODS: Subjects were assigned to receive either prolotherapy or corticosteroid injection for treatment of chronic lateral epicondylosis. Each subject underwent injection at baseline followed by a second injection 1 month later. OUTCOME MEASUREMENTS: Visual analog scale (VAS) self-rating of pain, quadruple visual analog scale (QVAS), and the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) were measured at baseline and at 1, 3, and 6 months' follow-up. RESULTS: Within each group, the analysis demonstrated statistically significant improvements in both VAS and DASH within the prolotherapy group with significant changes noted from baseline to 3 months (VAS: Δ2.38; 95% confidence interval [95% CI] 1.04-3.71, P = .004 and DASH: Δ19.89; 95% CI 5.73-34.04, P = .01), and baseline to 6 months (VAS: Δ2.63; 95% CI 0.61-4.62, P = .017 and DASH: Δ21.76; 9% CI 7.43-36.09, P = .009) after initial treatment, as well as in the QVAS from baseline to 3 months. The steroid group demonstrated a clinically and statistically significant change for DASH only at both 3-month (Δ13.33; 95% CI 0.68-25.99, P = .04) and 6-month (Δ15.56; 95% CI 1.30-29.81, P = .04) follow-up. Comparison of the subjects completing the study revealed no significant differences between the prolotherapy and the corticosteroid group for change in VAS, QVAS, or DASH, although the study lacked sufficient power to draw conclusions from this finding. Eighty-three percent of the subjects were satisfied with their overall improvement during the course of the study, without significant differences revealed between groups. Aside from injection-associated pain, no adverse reactions were reported. Seventeen subjects completed study protocol. CONCLUSIONS: Both prolotherapy and corticosteroid therapy were generally well tolerated and appeared to provide benefit of long duration. Small sample size precludes determining whether one therapy is superior to the other. Larger, controlled trials appear feasible and warranted on the basis of these findings.