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Contents lists available at ScienceDirect

Journal of Science and Medicine in Sport

journal homepage: www.elsevier.com/locate/jsams

Review

The Exercise and Sports Science Australia position statement:

Exercise medicine in cancer management
Sandra C. Hayes a,∗ , Robert U. Newton b,c , Rosalind R. Spence a , Daniel A. Galvão b
a
Queensland University of Technology, Institute of Health and Biomedical Innovation, Australia
b
Edith Cowan University, Exercise Medicine Research Institute, Australia
c
The University of Queensland, School of Human Movement and Nutrition Sciences, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Since Exercise and Sports Science Australia (ESSA) first published its position statement on
Received 13 December 2018 exercise guidelines for people with cancer, there has been exponential growth in research evaluating the
Received in revised form 25 April 2019 role of exercise pre-, during and post-cancer treatment.
Accepted 7 May 2019
Design and Methods: The purpose of this report is to use the current scientific evidence, alongside clin-
Available online xxx
ical experience and exercise science principles to update ESSA’s position statement on cancer-specific
exercise prescription.
Keywords:
Results: Reported in this position statement is a summary of the benefits accrued through exercise follow-
Exercise
Cancer
ing a cancer diagnosis and the strengths and limitations of this evidence-base. An exercise prescription
Guidelines framework is then proposed to enable the application of cancer-specific considerations for individu-
Prescription alisation, specificity, safety, feasibility and progression of exercise for all patients. Additional specific
Survivor exercise prescription considerations are provided for the presence of haematological, musculoskele-
Patient tal, systemic, cardiovascular, lymphatic, gastrointestinal, genitourinary and neurological disease- and
treatment-related concerns, as well as presence of co-morbid chronic disease. Further, we also identify
and discuss cancer-specific pragmatic issues and barriers requiring consideration for exercise prescrip-
tion.
Conclusions: While for the majority, multimodal, moderate to high intensity exercise will be appropriate,
there is no set prescription and total weekly dosage that would be considered evidence-based for all
cancer patients. Targeted exercise prescription, which includes the provision of behaviour change advice
and support, is needed to ensure greatest benefit (as defined by the patient) in the short and longer term,
with low risk of harm.
© 2019 Sports Medicine Australia. Published by Elsevier Ltd. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Practical implications weekly dosage that would be considered evidence-based for all
cancer patients.
• This document represents ESSA’s exercise and cancer position • Targeted exercise prescription, which includes the provision of
statement and has the purpose of guiding individualised, targeted behaviour change advice and support, is needed to ensure great-
exercise prescription to cancer patients through the application est benefit (as defined by the patient) is achieved in the short and
of evidence, clinical experience and exercise principles. longer term, with very low risk of harm.
• The exercise prescription that works best for whom and when
will be determined by patient assessment, identification and con- 1. Introduction
sideration of general and cancer-specific health issues and their
contribution to risk of morbidity and/or mortality, and subse- In 2009, Exercise and Sports Science Australia (ESSA) pub-
quent patient-driven goals. lished its first position statement on optimising cancer outcomes
• While for the majority, multimodal, moderate to high intensity through exercise.1 Since that time, the position statement has been
exercise will be appropriate, there is no set prescription and total used by health professionals to guide exercise prescription to can-
cer patients pre-, during and post-treatment, and has provided
the foundation for continuing education courses in upskilling the
∗ Corresponding author. workforce. In the past decade, cancer incidence in Australia has
E-mail address: [email protected] (S.C. Hayes). increased and cancer survival has continued to improve,2 ensuring

https://doi.org/10.1016/j.jsams.2019.05.003
1440-2440/© 2019 Sports Medicine Australia. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

Please cite this article in press as: Hayes SC, et al. The Exercise and Sports Science Australia position statement: Exercise medicine in
cancer management. J Sci Med Sport (2019), https://doi.org/10.1016/j.jsams.2019.05.003
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a rapidly expanding number of people living with a cancer diagnosis tory fitness, neuromuscular strength and quality of life during and
(>400,000 Australians are currently living with a cancer diagno- post-breast cancer treatment (particularly for those diagnosed with
sis in the previous five years). Further, there has been exponential early stage disease).43 In contrast, the evidence to support exercise
growth in published high quality, randomised, controlled trials that as being effective at improving survival outcomes for any cancer
have evaluated the effect of exercise on a range of cancer-related cohort is weak (findings come from underpowered, exploratory
outcomes across the cancer trajectory, from diagnosis through to analyses).38–41 There is strong evidence that exercise leads to
end of life. In recognition that Accredited Exercise Physiologists benefits when integrated during active treatment for a range of
(AEPs) require and seek assistance in translating this evidence to cancers,43 but no evidence to suggest that the specific timing of an
their exercise prescription practice for people with cancer, who exercise session matters (e.g., evidence showing exercise during
represent a growing population with diverse and cancer-specific chemotherapy infusion is more or less effective at improving sur-
health needs and priorities, we present a new ESSA exercise and vival outcomes versus before or after infusion is lacking). Following
cancer position statement. The purpose of this position statement a review of this literature, a forthcoming American College of Sports
is to: (1) provide a contemporary overview of the exercise and Medicine publication (to be published in Medicine and Science in
cancer evidence-base; and (2) present a framework for exercise Sports and Exercise, 2019) will provide exercise prescription guide-
prescription to patients, with cancer-specific considerations for lines specific to cancer-outcomes with a sufficient evidence-base
individualisation, specificity, safety, feasibility and progression. to do so. The ESSA exercise and cancer guideline update presents a
process that can guide the practical application of this evidence.

2. Evidence of exercise benefit following a cancer diagnosis

3. Recommended process for targeted, exercise
prescription for cancer patients
Benefits accrued through exercise during and beyond treat-
ment for cancer have been extensively reviewed. Specifically, a
When the evidence base for all cancer types, cancer-specific out-
recent publication reported that 140 meta-analyses have been
comes and different exercise prescriptions evaluated is reviewed in
published to date, with the majority (75%) showing statistically
light of its strengths and limitations and applied in practice along-
significant and clinically relevant benefit through exercise on
side generic exercise prescription principles, it provides a powerful
a range of treatment-related side effects, physical, functional,
foundation from which exercise can be used to improve the lives
and psychosocial outcomes.3 Our own review (date: 18/7/17;
of those diagnosed with cancer. Fig. 1, represents a recommended
search terms: ((“exercise”[MeSH Terms] OR “exercise”[All Fields])
process that can guide individualised, evidence-based assessment,
AND (“neoplasms”[MeSH Terms] OR “neoplasms”[All Fields])) AND
exercise prescription and follow-up to cancer patients (defined
(“2009”[PDAT] AND Review[ptyp])) identified more than 140
from herein as a person who has been diagnosed with cancer). It
systematic reviews or meta-analyses and more than 90 non-
incorporates cancer-specific considerations to all aspects of patient
systematic reviews on new or emerging topics. There now exists
care, including assessment and initial exercise prescription, as well
evidence of varying strength on the safety, feasibility and/or effi-
as exercise principles of progressive overload, periodisation and
cacy of exercise throughout the cancer continuum in a range of
autoregulation. Further, it incorporates the use of behaviour change
cancers, including but not limited to, more common cancers such
strategies, education and monitoring, to ensure a patient-centred
as breast,4 prostate,5 colorectal6 and lung7 cancer, as well as other
approach to the provision of care (specificity), while enabling
cancers including haematological,8 head and neck,9 cancers of
patients to develop the necessary skills to ensure exercise can ben-
childhood and adolescence,10 and gynaecological cancers,11,12 and
efit their health in the longer term. The process is as follows:
less common cancers such as brain,13 testicular14 and pancreatic.15
Some studies have specifically targeted patient cohorts with more
advanced disease,16,17 providing initial evidence beyond patients 1) Patient assessment, including patient and family health his-
with early-stage disease, generally considered ‘well’. tory (presence of comorbidities/additional chronic disease and
Outcomes evaluated in trials have also broadened. There is now related treatment); cancer diagnosis (previous and current);
trial evidence (again of varying strength) regarding the potential cancer treatment (previous, current and planned); risk, presence
positive effect of exercise for more contemporary treatment- and severity of treatment-related toxicities (acute, persistent
related side effects, such as chemotherapy-induced periph- and late side effects); and physical activity and exercise history.
eral neuropathy,18 myalgia and arthralgias,19,20 lymphoedema 2) Determine health issues and prioritise contribution of these to risk
(upper- and lower-limb),21,22 bone health,23–25 sarcopenia26,27 of morbidity and/or mortality. Exercise prescription following
and metabolic syndrome,28 sleep quality,29 cachexia,30 cognitive cancer diagnosis typically seeks to influence any one or more of
impairment31 and cardiotoxicity,32,33 as well as outcomes partic- a range of outcomes, including but not limited to prevention or
ularly relevant to the clinical and public health setting, such as management of disease- and treatment-related toxicities. The
treatment adherence or completion34–36 and cost-effectiveness.37 exercise prescription must be focussed on ameliorating issues
In the past five years, preliminary findings have also become avail- with greatest impact on health and survival.
able from phase 2 exploratory studies that have reported the effect 3) Identify patient capacity and intervention suitability determined
of exercise on survival outcomes.38–41 by considering economic, psychosocial and physiological con-
Despite the exponential growth in the number and quality straints (including contraindications), accessibility, preferences,
of clinical trials contributing to the broader evidence-base sup- self-efficacy, barriers and facilitators to exercise, and potential
porting exercise in oncology, there remains a preponderance of benefit.
studies in the breast cancer setting and/or involving ‘healthier, 4) Prescribe exercise according to patient-driven exercise-related
more active’ cancer patients,42 which is disproportionate to the goals.
characteristics of the wider cancer population. Further, there are 5) Reassessment and prescription modification by following points
varying levels of evidence in support of exercise as being safe, 1–4.
feasible and effective for various cancer cohorts, cancer subtypes,
stages of disease and outcomes of interest. For example within the Screening tools and guidelines, such as the ESSA Adult
breast cancer setting, there is strong evidence to support exercise Pre-Exercise Screening tool,44 Physical Activity Readiness
as being safe, feasible and effective at improving cardiorespira- Questionnaire,45 or the American College of Sports Medicine

Please cite this article in press as: Hayes SC, et al. The Exercise and Sports Science Australia position statement: Exercise medicine in
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Fig. 1. Recommended process for targeted exercise prescription for cancer patients.

(ACSM) guidelines for exercise testing and prescription46,47 are can only suggest potential components of the initial assessment; in
useful for developing an initial health and risk profile for an the end, clinical judgement that is based on the patient’s circum-
individual. However, these tools are not designed to collect the stances and exercise-related goals will dictate what is (and is not)
necessary additional information required to enable safe and feasi- assessed and why.
ble exercise prescription for cancer patients. Instead, information For a patient in the active treatment phase,52 it is best prac-
needs to be collected on all issues specified in point 1 above, most of tice to contact the treating clinician, informing them that exercise
which can be sourced directly from the patient. However, patient- prescription is being integrated into cancer care and providing
derived information, particularly with respect to risk of developing opportunity for comment or concerns. During treatment, the most
acute, persistent or late treatment-related side effects, needs to be appropriate clinician to liaise with will depend on the type and
supplemented with information derived from reputable sources. stage of cancer and treatment being received. For example, a urol-
The Australian Government online resource of cancer treatment ogist, medical oncologist or radiation oncologist may be the most
protocols (https://www.eviq.org.au) may be useful in this regard. appropriate clinician for those receiving treatment for prostate
This information (point 1 above) could be supplemented with cancer, chemotherapy for colorectal cancer or radiation therapy
questionnaires typically used in cancer research and clinical for head and neck cancer, respectively. A general practitioner
management to measure and track changes in patient-reported will likely be the most relevant clinician to liaise with during
outcomes including quality of life (e.g., Functional Assessment of the post-treatment survivorship phase. Discussions with a patient
Cancer Therapy (FACT) – General,48 Patient-reported Outcomes during the initial assessment (point 1 above) will allow an AEP
Measurement Information System (PROMIS)49 ), treatment-related to identify the most appropriate clinician to communicate with
side effects (e.g., PROMIS,49 FACT-Breast50 ) and exercise self- and to establish consent to discuss patient information with this
efficacy.51 The initial assessment could also include a battery clinician.
of physical/functional tests including assessments (or surrogate The need for medical clearance prior to exercise testing and pre-
measures) of cardiorespiratory fitness, function, strength, balance, scription for cancer patients is a topic of debate. Endorsing a blanket
body composition and bone health. requirement for medical clearance for all cancer patients creates an
Responses to screening tools, AEP-derived template of ques- additional barrier to the provision of exercise prescription.53 Fur-
tions, externally-sourced treatment-related information, patient- ther, given the known harm of inactivity, only in rare circumstances
completed questionnaires, and results from physical assessment would a targeted, exercise prescription be contraindicated. Yet the
will allow an AEP and cancer patient to discuss point 2 above, potential benefits of targeted exercise prescription prior, during
and can aid the clinical judgement as to whether further test- and post-cancer treatment may not be recognised by all treating
ing, medical investigation or medical clearance is needed prior clinicians and may contribute to a situation whereby those patients
to commencing an exercise program. While there is no ‘correct’ most in need are the least likely to receive medical clearance (i.e.,
or ‘optimal’ number and type of patient-reported or objectively- AEPs receive medical clearance and subsequent referral for only the
measured outcomes included in an initial assessment, patient test ‘well’ cancer patient). However, requesting medical clearance can
burden must be considered and limited. What must be measured instigate communication between the AEP and a treating clinician,
are the minimum parameters necessary to prescribe a safe, feasible and the subsequent transfer of relevant exercise considerations
and effective exercise program. The inclusion of additional assess- that a patient may or may not be aware of. Therefore, the need
ments should only occur when benefit of the information collected for medical clearance should be considered on a case by case basis,
outweighs the burden of its assessment. Overall, research findings but direct communication with at least one member of the treating

Please cite this article in press as: Hayes SC, et al. The Exercise and Sports Science Australia position statement: Exercise medicine in
cancer management. J Sci Med Sport (2019), https://doi.org/10.1016/j.jsams.2019.05.003
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team who can provide clinical guidance when needed53 is recom- of evidence suggests beneficial prescription parameters for a num-
mended for all patients. ber of side effects and treatment-related outcomes (Table 2). In
Following initial assessment (point 1 above), the next task is some cases, it will be appropriate to look to other disease states
to assist a cancer patient to identify their specific health (psycho- or chronic conditions for exercise principles and guidelines tar-
logical and/or physiological), quality of life and survival concerns geting similar outcomes (e.g., exercise and obesity guidelines for
(point 2 above) and to discuss potential benefit through exer- obese women receiving treatment for endometrial cancer; exer-
cise. Goals of exercise need to be prioritised according to what cise and osteoporosis guidelines for osteopenic women receiving
is of most value to the patient (e.g., symptom management, aromatase inhibitors for breast cancer or men receiving androgen
improving mood, minimising declines in cardiorespiratory fitness, deprivation therapy for prostate cancer; Table 2). However, appro-
reversing loss of muscle mass, survival), noting that some may priate caution is necessary given that the generalisability of safety,
prioritise long-term over short-term goals, psychosocial benefits feasibility and efficacy findings among comorbidities is unknown.
over physiological or functional benefits, and that goals and pri- Further, as the benefits of exercise following cancer are better elu-
orities for all will likely change over time. A targeted exercise cidated, it is prudent for exercise professionals to remain cognisant
prescription is one that seeks to achieve these goals. Patient-factors of potential harm through exercise, to educate patients about, and
that may influence adherence to this targeted prescription then monitor presence of, contraindications, which largely relate to the
need to be identified and discussed (point 3 above). This includes presence of new or unusual changes to existing signs and symp-
understanding patient circumstances (including current functional toms (Table 2). Our approach of placing strong emphasis on using
capacity, physical limitations/constraints) and preferences pertain- changes in signs and symptoms to guide exercise prescription (and
ing to type, frequency, intensity and duration, available finances exercise prescription modifications), while continuing to acknowl-
to support exercise participation (which will influence degree edge the relative risks associated with abnormal haematological or
to which the exercise is supervised and where), health literacy, other markers (e.g., oxygen saturation levels at rest), when known,
exercise self-efficacy, ability to identify and problem solve exercise- is similar to that recently suggested by others.54
related barriers (which may be cancer-specific or general), the
support network available to assist integrating exercise during and 3.1. Core components of exercise prescription: mode, intensity,
beyond cancer management, and motivation to achieve goals via frequency, duration, total exercise dosage, progression,
exercise. periodisation and autoregulation
It will also be necessary to educate the patient about what
constitutes realistic exercise-related goals (e.g., maintenance of Exercise mode: A multimodal exercise program, comprising aer-
function, slowing declines or improvements in function), with the obic and resistance (targeting large and specific muscle groups)
patient’s current cancer survivorship phase (pre-, during, post- exercise should be included in a patient’s exercise prescription
treatment with treatment aim being cure, substantive remission (Table 1). However, the focus or emphasis of aerobic versus resis-
or palliation52 ) influencing expectations. Further, educating the tance exercise must be determined by a patient’s needs and goals.
patient about what exercise components will be necessary for For example, a woman with endometrial cancer advised to lose
achieving specific goals, particularly when patient exercise pref- weight through dietary change, will need to increase emphasis on
erences fail to align with achieving their desired goal(s), will be resistance training to ensure preservation of lean tissue during peri-
relevant and important. In these instances, an AEP will need to ods of weight loss, whereas a lung cancer patient who needs to
help guide the patient in recognising what they are willing to do improve cardiorespiratory fitness will need to increase emphasis
to achieve a goal (even if not enjoyable) versus what they are not on aerobic exercise. Exercise prescription emphasis requirements
willing to do. The final exercise prescription (point 4 above) repre- based on specific considerations are presented in Table 2. While
sents one that considers exercise goals alongside health priorities, there is cross-over in exercise benefit (i.e., resistance exercise can
and ensures the patient is central to the discussion and decisions produce a cardiorespiratory adaptation and aerobic exercise can
made. produce a neuromuscular strength and endurance adaptation in
Frequency and components of reassessment and prescription cancer patients55,56 ), the magnitude of benefit will be influenced
modification (point 5 above) will be influenced by the exercise pre- by training specificity.56 As such, it is appropriate to consider
scription goals, whether the patient is in an active treatment phase, patient preferences and resources when prescribing exercise mode,
likelihood of changes in disease- and treatment-related toxicities particularly during the early stages of exercise prescription in
that may influence or be influenced by the exercise prescription deconditioned patients. However, a patient also needs to be edu-
and access to AEP services. Of note, when the process of targeted cated with respect to optimal exercise mode for achieving their
exercise prescription is followed, AEPs can readily identify when defined exercise goals. Further, the specific modes chosen within
a patient may benefit from referral to another allied health pro- aerobic and resistance exercise (e.g., water-based exercise versus
fessional. For example, referral to a dietitian for those in need of use of ergometers versus walking, or free-weights versus machine-
nutritional advice, referral to supportive services (e.g., peer support weights versus therabands) should be influenced by cancer-specific
connections) and health professionals including a psychologist, factors (Table 2), as well as patient preferences.
specialist oncology nurse or counsellor for those reporting concerns The inclusion of balance and flexibility training may improve the
with fear of recurrence, or referral to a physiotherapist for those ability to undertake daily activities with reduced falls risk, discom-
with acute or persistent musculoskeletal or neurological issues. fort, pain or concerns.57 Yoga and Tai chi, which have been shown
Further, an AEP may play a pivotal role in referring a patient back to improve quality of life and other cancer-related outcomes58–60
to the treating team for clinical review of new or changing disease- (Table 2), are potentially time efficient and beneficial means for
and treatment-related toxicities or side effects, which may or may incorporating balance training into exercise prescription for those
not be associated with progression of disease. in need. The inclusion of pelvic floor exercises is also particularly
While it is not possible to provide a specific exercise prescrip- important for patients with or at high-risk of urinary and faecal
tion based on an individual’s diagnosis (and likely never will be), incontinence (such as those treated for genitourinary, colorectal
there are some general exercise prescription guidelines that will or gynaecological cancers), but likely appropriate for the majority
be appropriate for the majority of cancer patients, including chil- of adult and geriatric patients.61 Further, for highly decondi-
dren through to geriatric patients (Table 1). Also, the growing body tioned patients or patients nearing end of life, exercise prescription

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Table 1
Foundation exercise prescription guidelines for cancer patients.

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Acute or chronic cancer-related concerns requiring specific exercise prescription considerationa,b .77–99
Table 2
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Table 2 (Continued)
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Table 2 (Continued)
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Table 2 (Continued)
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Table 2 (Continued)
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Table 2 (Continued)
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Table 2 (Continued)
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Table 2 (Continued)
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Table 2 (Continued)
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Table 2 (Continued)
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Table 2 (Continued)
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Table 2 (Continued)
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emphasis may need to be placed on ‘mobility’ exercises (e.g., a with advanced stage disease, a starting exercise prescription may
range of specific upper- and lower-body exercises undertaken with need to involve multiple short bouts (5–10 min duration) daily, to
low/no load) to accommodate and progress (when relevant) car- accumulate at least 20 min on any given day. As exercise capacity
diovascular and respiratory function, neuromuscular strength and improves, progression towards longer sessions of at least 20 min
endurance, and flexibility capabilities. duration on most days of the week is recommended. The 20 min
While focus should be given to targeted exercise prescription cut-point being proposed (which has also been suggested by oth-
to address priority health issues, any kind of activity that a patient ers previously65 ) is not distinct and less duration per day may
considers enjoyable or perceives as positively influencing cancer- be more optimal for some patients (e.g., palliative patients with
related outcomes (e.g., pain, quality of life) should be permitted lung cancer). Instead this suggested cut-point reflects a pragmatic
or even encouraged. These activities (e.g., low-intensity yoga, Tai exercise duration whereby there is sufficient time for an exercise
chi, meditation) can supplement the exercise prescription and will prescription that allows for a warm-up and cool-down component,
enhance adherence while providing additional physiological and sufficient disruption to cardiovascular, respiratory, neuromuscu-
psychological benefit. The exception to this recommendation is lar, endocrine and immune homeostasis, and requires patients to
when a specific activity is considered contraindicated or risk of actively plan/schedule their exercise, which in turn will aid longer
harm outweighs benefit (e.g., a brain cancer patient with bal- term positive behaviour change.66 Further, sessions of a minimum
ance concerns who wants to keep road cycling, a paediatric cancer of 20-min duration could allow for sufficient weekly exercise dose
patient with thrombocytopenia who wants to continue playing while incorporating rest days (noting that rest days may be pur-
competitive rugby, an osteoporotic breast cancer patient who is posely scheduled into the exercise prescription due to pragmatic
taking aromatase inhibitors and wants to only do water-based exer- reasons or preferences, or be unplanned and occur due to the pres-
cise). When this is the case, patient education around benefit versus ence of one or more barriers).
risk, and revisiting short and long term goals and priorities may Total exercise dosage: Intensity, frequency and duration com-
help in steering the patient towards safe, feasible and effective bine to produce total dosage of exercise prescription over a defined
exercise (e.g., advising use of a road bike on a wind-trainer for the period (e.g., week or month). Information gathered during the ini-
brain cancer patient, encouraging participation in certain compo- tial assessment, with particular attention to current and previous
nents of training but not game play for the paediatric cancer patient exercise, will enable an AEP to determine the appropriate starting
with thrombocytopenia; doing two water-based sessions per week, exercise dosage. Erring on the side of caution (that is, prescribe less
supplemented with two land-based strength sessions, including than more) in the initial phases of an exercise program, particularly
appropriate impact loading, per week for the osteoporotic breast for sedentary or deconditioned patients is recommended. Note, the
cancer patient). targets promoted in physical activity guidelines for cancer patients
Intensity: Patients should not be restricted to low-intensity exer- (that is, >150 min of moderate intensity aerobic activity/>75 min
cise, nor is high-intensity exercise contraindicated for all. However, of vigorous intensity aerobic activity plus 2 resistance exercise
there will be times when low-intensity exercise is recommended sessions, per week67 ) may not represent an appropriate starting
(e.g., a patient with nausea that worsens with moderate inten- weekly exercise dosage for the majority of cancer patients, nor
sity exercise) and when high intensity exercise may need to be may they ever be achievable for specific patients. Studies involv-
avoided (e.g., immediate weeks post-surgery to avoid adversely ing women with either ovarian or metastatic breast cancer, and
influencing wound healing; presence of a blood clot related to patients with either lung or pancreatic cancer, have specifically
a peripherally-inserted central catheter). Helping patients under- shown that while some may be able to achieve physical activity
stand what constitutes low, moderate and high intensity exercise targets through exercise prescription at least some of the time, oth-
through the use of one or more tools, including rating of per- ers were never able to achieve the target during the intervention
ceived exertion scale, heart rate and repetition maximum, is period assessed.30,68,69 Further, for some, the target may be unnec-
recommended. Self-reported methods of assessing intensity are essary for accruing benefit (that is, benefits have been observed
considered particularly useful for those at risk of their heart rate with lower dosages).63
response being influenced by treatment-induced cardiac changes It will be important for patients to have an understanding of
or certain treatments (e.g., specific chemotherapeutic agents or what constitutes their ideal weekly exercise dosage, and whether
HER2 targeting drugs). Self-reported methods are also considered there is need for this dosage to be modified over time. The known
useful for those experiencing ‘good’ and ‘bad’ days/weeks during dose-response relationship between exercise and physical and psy-
an active treatment period. Further, helping patients understand chosocial outcomes is relevant for patients with cancer. Evidence
what constitutes a normal physiological response to exercise and from a large, systematic review of cohort studies evaluating the
that they are in the best position to measure and monitor exer- association between physical activity post-cancer and survival out-
tion (either by rating perceived exertion with or without objective comes suggest that a weekly exercise dosage of around 150 min
measurement of heart rate) may improve exercise self-efficacy.62 of moderate intensity (or equivalent volume) exercise per week
The intensity of exercise sessions, including whether interval represents the approximate dosage beyond which there may be
training, impact loading, explosive dynamic training or other, is diminishing benefits gained through undertaking higher dosages.70
included should be determined by patient-driven factors (short and Nonetheless, there is some evidence to suggest that exercising
long term goals and interests) and cancer-specific factors (indica- at higher dosages may contribute to additional benefit in spe-
tions and contraindications, see Table 2). Evidence to support for cific outcomes (e.g., fitness) for specific cohorts (e.g., patients with
example, high intensity interval training over moderate intensity colon cancer).71 While future research continues to improve our
continuous duration training for improving cardiorespiratory fit- understanding about what constitutes minimum and maximum
ness in the longer term in cancer patients is currently unclear.6,63 exercise dosage thresholds and for whom, it is reasonable to suggest
However, for a patient who needs to improve fitness in a spe- that the majority of cancer survivors can safely undertake regu-
cific and short time frame (e.g., lung cancer patient with only 4 lar exercise, when commenced at conservative dosages, progressed
weeks prior to surgery),64 there may need to be greater emphasis gradually and appropriately modified for the presence of disease-
on undertaking exercise at high intensity. and treatment-related side effects and co-morbidities (Table 2).
Frequency and duration: Duration of any given exercise session There is potential for benefit in the translation of research
will influence frequency of exercise bouts per day or week. For into periodisation to exercise prescription for cancer patients and
deconditioned patients, immediately post-surgery and/or for those several exercise oncology trials have incorporated various periodi-

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cancer management. J Sci Med Sport (2019), https://doi.org/10.1016/j.jsams.2019.05.003
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Cancer-specific pragmatic issues and barriers requiring consideration for exercise prescriptiona .
Table 3
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cancer management. J Sci Med Sport (2019), https://doi.org/10.1016/j.jsams.2019.05.003
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Table 3 (Continued)
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Table 3 (Continued)
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Table 3 (Continued)
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sation models.25,72 Variation in volume and intensity across the understanding what appropriate progression means and how it
week or within treatment cycles may stimulate greater physio- can be defined. For example, helping regular exercisers to modify
logical adaptation, and reduce boredom and risk of over-training. expectations around physical response to exercise and to appre-
Further, periodised plans designed for optimal preparation for spe- ciate that minimising declines in function during active treatment
cific events, such as surgery or commencement of chemotherapy or periods is indicative of exercise benefit. For those who are sedentary
radiation therapy, or to specifically address particular health issues at diagnosis, helping them to overcome fears associated with ‘doing
should be considered. This may include sequential and cycling too much’ and learning differences between treatment-related side
phases of emphasis on specific exercise modes such as resistance, effects and normal, short term physiological responses to exercise
aerobic, balance, and impact training. For example, the prescrip- overload, will likely be an important part of provision of exercise
tion of an extended phase of heavy resistance training before prescription and support. However, it will also be necessary to help
progressing to impact loading for maintaining bone density25 ; patients avoid overtraining, which may bring with it higher risk of
planned emphasis on low intensity exercise when treatment- physical stress, injury, and compromised immune function, with
related symptoms are severe, and high intensity exercise when unknown effect on key cancer-outcomes, such as quality of life,
symptoms are mild; or emphasis on high load resistance train- treatment tolerance and effectiveness, and even survival. Signs of
ing with water-based aerobic exercise during the initial weeks of overtraining would include the presence of unusual symptoms,
exercise prescription for obese patients (Table 2). increased severity of symptoms and changes in symptom trajec-
In recognition that cancer patients experience marked fluctua- tory (e.g., persist longer than expected). Overall, a key role of an
tions in exercise tolerance, capacity and self-efficacy, particularly AEP is to assess the safety, feasibility and effect of specific exer-
during the active treatment phase, it is paramount to ensure flexi- cises, weekly dosage and pace of progression within the framework
bility is built into the exercise prescription. The prescription should of an individual cancer patient’s risk profile and exercise-related
enable patients to autoregulate session, weekly and monthly exer- goals.
cise dosage to accommodate ‘good days/weeks’ (whereby higher
intensity and/or dosage may be undertaken) and ‘bad days/weeks’ 3.2. Behaviour change strategies — an important component of
(whereby reduced intensity and/or total dosage may be required to exercise prescription
accommodate symptoms). Autoregulation can occur, when neces-
sary, through modifications to mode, intensity, frequency, duration Through the implementation of behaviour change techniques
and/or total volume, guided by objective (e.g., heart rate, rep- including goal setting, self-monitoring, individualised education,
etitions completed) and/or subjective (e.g., rating of perceived exercise prescription and feedback, and social support, exercise
exertion) measures. Examples of the implementation of autoreg- adherence can be improved.75 This, in turn, facilitates achiev-
ulation in the oncology setting have been previously published ing predefined exercise goals. Identifying and helping a patient
for aerobic73 and resistance74 exercise. Overall, the total exercise problem-solve general and cancer-specific issues and barriers to
dosage for a defined period should seek to achieve the desired exercise also forms an essential component of exercise prescrip-
physical and mental health benefit(s), while balancing risks of over- tion (Table 3). Finally, incorporating behaviour change strategies as
training, maladaptation, suboptimal, low priority or unnecessary part of the routine provision of exercise prescription will improve
exercise. patient exercise self-efficacy,76 and as such, provide them with the
Progression: How to approach the progression of exercise pre- tools to use exercise to benefit their longer term health.
scription will differ depending on whether the patient is in the Education and monitoring of exercise prescription: In addition to
pre-, during or post-treatment cancer survivorship phase.52 For standard exercise-related education topics, including appropriate
example, physical and physiological declines are typically observed clothing and footwear, hydration, and safe and appropriate use of
during active treatment periods, and also during periods of disease equipment, a patient needs to be equipped to monitor the pres-
progression. Consequently, an exercise intensity that is moder- ence and severity of treatment-related side effects before, during
ate in the early weeks of treatment may elicit a physiological and following exercise sessions and to be able to report on exer-
response indicative of vigorous intensity exercise in the final weeks cise response to the AEP. This represents important information
of chemotherapy or when the disease has advanced. As such, that will enable appropriate modification to exercise prescription
minimising regression of total exercise dosage and relative inten- parameters for the purpose of autoregulation, periodisation and
sity, or maintaining these parameters throughout the treatment progression. Further, this information also allows for an adverse
period could be considered appropriate progression and incorpo- event or contraindication to exercise to be readily identified and
rates patient autoregulation as discussed above. managed accordingly. The presence of an unusual symptom or
For those who have completed treatment with a curative an unusual change to an existing symptom, rather than the pres-
intent, it is generally reasonable to expect that exercise can be ence of a persistent treatment-related side effect or symptom in
progressed steadily through increased overall dosage via mod- itself, is more likely to represent an exercise contraindication. To
ifications to mode, frequency, intensity and duration. However, detect the ‘unusual’, it is first necessary to have a clear under-
it remains important to consider the influence of any persis- standing of what constitutes ‘normal’ or ‘expected’ for any given
tent treatment-related toxicities or co-morbidities and the risk patient.
of new issues, as well as the potential challenge of returning to
daily activities including work, on how progression should and
could be defined. For example, returning to domestic chores, paid 4. Conclusion
employment, volunteering or family responsibilities after treat-
ment, while maintaining previous weekly exercise dosage could be Overall, evidence supports that the implementation of exercise
considered appropriate progression in the first 3–6 months post- prescription brings with it reduced morbidity, improved function
treatment. and quality of life, and potential for improved survival, with very
In all cases, the goal of progression is to facilitate and main- low risk of harm. However, the strength of the evidence in support
tain benefits derived through exercise prescription in the short and of exercise safety, feasibility and benefit is dependent on cancer
longer term. Those who are already meeting or exceeding public type and outcome of interest. While for the majority, multimodal,
health physical activity guidelines or conversely, those who are moderate to high intensity exercise will be appropriate, there is no
sedentary at time of diagnosis, may require more assistance with set prescription and total weekly dosage that would be considered

Please cite this article in press as: Hayes SC, et al. The Exercise and Sports Science Australia position statement: Exercise medicine in
cancer management. J Sci Med Sport (2019), https://doi.org/10.1016/j.jsams.2019.05.003
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24 S.C. Hayes et al. / Journal of Science and Medicine in Sport xxx (2019) xxx–xxx

evidence-based for all cancer patients. Appropriate exercise pre- 17. Heywood R, McCarthy AL, Skinner TL. Efficacy of exercise interventions in
scription for cancer patients needs to be targeted and individualised patients with advanced cancer: a sstematic review. Arch Phys Med Rehabil 2018;
99(12):2595–2620.
according to patient- and cancer-specific considerations. 18. Duregon F, Vendramin B, Bullo V et al. Effects of exercise on cancer patients
suffering chemotherapy-induced peripheral neuropathy undergoing treatment:
Acknowledgements a systematic review. Crit Rev Oncol Hematol 2018; 121:90–100.
19. Irwin ML, Cartmel B, Gross CP et al. Randomized exercise trial of aromatase
inhibitor-induced arthralgia in breast cancer survivors. J Clin Oncol 2015;
We acknowledge and thank the following clinicians, exercise 33(10):1104–1111.
scientists and AEPs and consumer advocates for their considered 20. Nyrop KA, Callahan LF, Cleveland RJ et al. Randomized controlled trial of
a home-based walking program to reduce moderate to severe aromatase
review and comment on this position statement: Medical Oncol- inhibitor-associated arthralgia in breast cancer survivors. Oncologist 2017;
ogists – Dr Di Adams, Professor Michael Friedlander; Medical 22(10):1238–1249.
Oncologist and Clinical Haematologist - Dr John Bashford; Radi- 21. Bloomquist K, Oturai P, Steele ML et al. Heavy-load lifting: acute response in
breast cancer survivors at risk for lymphedema. Med Sci Sports Exerc 2018;
ation Oncologists – Professor Nigel Spry, Associate Professor Colin
50(2):187–195.
Tang; Cancer Surgeon – Professor Chris Pyke, Professor Christobel 22. Iyer NS, Cartmel B, Friedman L et al. Lymphedema in ovarian cancer survivors:
Saunders; Gynaecological Oncologist – Professor Andreas Ober- Assessing diagnostic methods and the effects of physical activity. Cancer 2018;
124(9):1929–1937.
mair; Urologist – Professor Dickon Hayne; Clinical Haematologist
23. Taaffe DR, Galvao DA, Spry N et al. Immediate versus delayed exercise in men
– Dr Andrew Nicol; Medical Registrar in Infectious Diseases – Dr initiating androgen deprivation: effects on bone density and soft tissue compo-
Luke Spence; General Practitioner – Dr Tania Jardine; exercise sci- sition. BJU Int 2018.
entists and AEPs – Dr Carolina Sandler, Mr Kyle Smith; Cancer 24. Winters-Stone KM, Dobek JC, Bennett JA et al. Skeletal response to resistance
and impact training in prostate cancer survivors. Med Sci Sports Exerc 2014;
Consumer Advocates– Mr Raymond Bernstein, Ms Leonie Young, 46(8):1482–1488.
Mr Robert Kelly. We would also like to acknowledge the impor- 25. Newton RU, Galvao DA, Spry N et al. Exercise mode specificity for preserving
tant contributions made by the reviewers – comments and queries spine and hip BMD in prostate cancer patients. Med Sci Sports Exerc 2018.
26. Adams SC, Segal RJ, McKenzie DC et al. Impact of resistance and aerobic exer-
received throughout the blinded, peer-review process undoubtedly cise on sarcopenia and dynapenia in breast cancer patients receiving adjuvant
improved the quality of this publication. SH is supported by a Can- chemotherapy: a multicenter randomized controlled trial. Breast Cancer Res
cer Council Queensland Fellowship. RN and DG are funded by a Treat 2016; 158(3):497–507.
27. Galvao DA, Taaffe DR, Spry N et al. Combined resistance and aerobic exercise
National Health and Medical Research Council Centre for Research program reverses muscle loss in men undergoing androgen suppression therapy
Excellence in Prostate Cancer Survivorship. for prostate cancer without bone metastases: a randomized controlled trial. J Clin
Oncol 2010; 28(2):340–347.
28. Dieli-Conwright CM, Courneya KS, Demark-Wahnefried W et al. Effects of Aer-
References obic and resistance exercise on metabolic syndrome, sarcopenic obesity, and
circulating biomarkers in overweight or obese survivors of breast cancer: a
1. Hayes SC, Spence RR, Galvao DA et al. Australian Association for Exercise and randomized controlled trial. J Clin Oncol 2018; 36(9):875–883.
Sport Science position stand: optimising cancer outcomes through exercise. J 29. Rogers LQ, Courneya KS, Oster RA et al. Physical activity and sleep quality
Sci Med Sport 2009; 12(4):428–434. in breast cancer survivors: a randomized trial. Med Sci Sports Exerc 2017;
2. Australian Institute of Health and Welfare. Cancer survival and prevalence in 49(10):2009–2015.
Australia: period estimates from 1982 to 2010, In: AIHW, ed. Vol Cancer Series 30. Solheim TS, Laird BJA, Balstad TR et al. A randomized phase II feasibility trial of a
no. 69. Cat. no. CAN 65. Canberra, Australia, AIHW, 2012. multimodal intervention for the management of cachexia in lung and pancreatic
3. Fuller JT, Hartland MC, Maloney LT et al. Therapeutic effects of aerobic and resis- cancer. J Cachexia Sarcopenia Muscle 2017; 8(5):778–788.
tance exercises for cancer survivors: a systematic review of meta-analyses of 31. Hartman SJ, Nelson SH, Myers E et al. Randomized controlled trial of increasing
clinical trials. Br J Sports Med 2018; 52(20):1311. physical activity on objectively measured and self-reported cognitive function-
4. Hayes SC, Rye S, Disipio T et al. Exercise for health: a randomized, controlled ing among breast cancer survivors: The memory & motion study. Cancer 2018;
trial evaluating the impact of a pragmatic, translational exercise intervention on 124(1):192–202.
the quality of life, function and treatment-related side effects following breast 32. Jones LW, Fels DR, West M et al. Modulation of circulating angiogenic factors and
cancer. Breast Cancer Res Treat 2013; 137(1):175–186. tumor biology by aerobic training in breast cancer patients receiving neoadju-
5. Crawford-Williams F, March S, Goodwin BC et al. Interventions for prostate vant chemotherapy. Cancer Prev Res (Phila) 2013; 6(9):925–937.
cancer survivorship: A systematic review of reviews. Psychooncology 2018; 33. Scott JM, Nilsen TS, Gupta D et al. Exercise therapy and cardiovascular toxicity
27(10):2339–2348. in cancer. Circulation 2018; 137(11):1176–1191.
6. Devin JL, Jenkins DG, Sax AT et al. Cardiorespiratory fitness and body compo- 34. Courneya KS, McKenzie DC, Mackey JR et al. Effects of exercise dose and type
sition responses to different intensities and frequencies of exercise training in during breast cancer chemotherapy: multicenter randomized trial. J Natl Cancer
colorectal cancer survivors. Clin Colorectal Cancer 2018; 17(2):e269–e279. Inst 2013; 105(23):1821–1832.
7. Edvardsen E, Skjonsberg OH, Holme I et al. High-intensity training following lung 35. Courneya KS, Segal RJ, Mackey JR et al. Effects of aerobic and resistance exer-
cancer surgery: a randomised controlled trial. Thorax 2015; 70(3):244–250. cise in breast cancer patients receiving adjuvant chemotherapy: a multicenter
8. Wiskemann J, Dreger P, Schwerdtfeger R et al. Effects of a partly self- randomized controlled trial. J Clin Oncol 2007; 25(28):4396–4404.
administered exercise program before, during, and after allogeneic stem cell 36. van Waart H, Stuiver MM, van Harten WH et al. Effect of low-intensity
transplantation. Blood 2011; 117(9):2604–2613. physical activity and moderate- to high-intensity physical exercise during
9. Jackson C, Dowd AJ, Capozzi LC et al. A turning point: Head and neck cancer adjuvant chemotherapy on physical fitness, fatigue, and chemotherapy com-
patients’ exercise preferences and barriers before and after participation in an pletion rates: results of the paces randomized clinical trial. J Clin Oncol 2015;
exercise intervention. Eur J Cancer Care (Engl) 2018; 27(2):e12826. 33(17):1918–1927.
10. Morales JS, Valenzuela PL, Rincon-Castanedo C et al. Exercise training in child- 37. Gordon LG, DiSipio T, Battistutta D et al. Cost-effectiveness of a pragmatic exer-
hood cancer: A systematic review and meta-analysis of randomized controlled cise intervention for women with breast cancer: results from a randomized
trials. Cancer Treat Rev 2018; 70:154–167. controlled trial. Psychooncology 2017; 26(5):649–655.
11. Zhou Y, Cartmel B, Gottlieb L et al. Randomized trial of exercise on quality 38. Courneya KS, Segal RJ, McKenzie DC et al. Effects of exercise during adju-
of life in women with ovarian cancer: women’s activity and lifestyle study in vant chemotherapy on breast cancer outcomes. Med Sci Sports Exerc 2014;
connecticut (WALC). J Natl Cancer Inst 2017; 109(12). 46(9):1744–1751.
12. Basen-Engquist K, Carmack C, Brown J et al. Response to an exercise intervention 39. Courneya KS, Friedenreich CM, Franco-Villalobos C et al. Effects of supervised
after endometrial cancer: differences between obese and non-obese survivors. exercise on progression-free survival in lymphoma patients: an exploratory
Gynecol Oncol 2014; 133(1):48–55. follow-up of the HELP Trial. Cancer Causes Control 2015; 26(2):269–276.
13. Capozzi LC, Boldt KR, Easaw J et al. Evaluating a 12-week exercise program for 40. Wiskemann J, Kleindienst N, Kuehl R et al. Effects of physical exercise on sur-
brain cancer patients. Psychooncology 2016; 25(3):354–358. vival after allogeneic stem cell transplantation. Int J Cancer 2015; 137(11):
14. Adams SC, DeLorey DS, Davenport MH et al. Effects of high-intensity aer- 2749–2756.
obic interval training on cardiovascular disease risk in testicular cancer 41. Hayes SC, Steele ML, Spence RR et al. Exercise following breast cancer:
survivors: a phase 2 randomized controlled trial. Cancer 2017; 123(20): exploratory survival analyses of two randomised, controlled trials. Breast Cancer
4057–4065. Res Treat 2018; 167(2):505–514.
15. Yoh K, Nishikawa H, Enomoto H et al. Effect of exercise therapy on sarcopenia in 42. Spence R, DiSipio T, Schmitz K et al. Is unsupervised exercise following breast
pancreatic cancer: a study protocol for a randomised controlled trial. BMJ Open cancer safe for all women? Int J Phys Med Rehabil 2014; 2(3).
2018; 7(5):1. 43. Speck RM, Courneya KS, Masse LC et al. An update of controlled physical activity
16. Dittus KL, Gramling RE, Ades PA. Exercise interventions for individuals with trials in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv
advanced cancer: a systematic review. Prev Med 2017; 104:124–132. 2010; 4(2):87–100.

Please cite this article in press as: Hayes SC, et al. The Exercise and Sports Science Australia position statement: Exercise medicine in
cancer management. J Sci Med Sport (2019), https://doi.org/10.1016/j.jsams.2019.05.003
G Model
JSAMS-2069; No. of Pages 25 ARTICLE IN PRESS
S.C. Hayes et al. / Journal of Science and Medicine in Sport xxx (2019) xxx–xxx 25

44. Norton K, Norton L. Pre-Exercise Screening: Guide to the Australian Adult Pre- 73. Kirkham AA, Bonsignore A, Bland KA et al. Exercise prescription and adher-
Exercise Screening System, Australia, Exercise and Sport Science Australia Fitness ence for breast cancer: one size does not FITT All. Med Sci Sports Exerc 2018;
Australia and Sports Medicine Australia, 2011. 50(2):177–186.
45. Thomas S, Reading J, Shephard RJ. Revision of the physical activity readiness 74. Fairman CM, Zourdos MC, Helms ER et al. A scientific rationale to improve
questionnaire (PAR-Q). Can J Sport Sci 1992; 17(4):338–345. resistance training prescription in exercise oncology. Sports Med 2017;
46. Riebe D, Franklin B, Thompson P et al. Updating ACSM’s recommendations 47(8):1457–1465.
for exercise preparticipation health screening. Med Sci Sports Exerc 2015; 75. Turner RR, Steed L, Quirk H et al. Interventions for promoting habitual exer-
47(11):3473–3479. cise in people living with and beyond cancer. Cochrane Database Syst Rev 2018;
47. Riebe D, Ehrman J, Liguori G et al. ACSM’s Guidelines for Exercise Testing and 9:CD010192.
Prescription, tenth edition Philadelphia, Wolters Kluwer, 2018. 76. Craike MJ, Gaskin CJ, Mohebbi M et al. Mechanisms of physical activity behavior
48. Webster K, Cella D, Yost K. The Functional Assessment of Chronic Illness Ther- change for prostate cancer survivors: a cluster randomized controlled trial. Ann
apy (FACIT) Measurement System: properties, applications, and interpretation. Behav Med 2018; 52(9):798–808.
Health Qual Life Outcomes 2003; 1:79. 77. Ibanez K, Espiritu N, Souverain RL et al. Safety and feasibility of reha-
49. Cella D, Riley W, Stone A et al. The Patient-Reported Outcomes Measurement bilitation interventions in children undergoing hematopoietic stem cell
Information System (PROMIS) developed and tested its first wave of adult transplant with thrombocytopenia. Arch Phys Med Rehabil 2018; 99(2):
self-reported health outcome item banks: 2005–2008. J Clin Epidemiol 2010; 226–233.
63(11):1179–1194. 78. Fu JB, Tennison JM, Rutzen-Lopez IM et al. Bleeding frequency and characteristics
50. Brady MJ, Cella DF, Mo F et al. Reliability and validity of the Functional Assess- among hematologic malignancy inpatient rehabilitation patients with severe
ment of Cancer Therapy-Breast quality-of-life instrument. J Clin Oncol 1997; thrombocytopenia. Support Care Cancer 2018; 26(9):3135–3141.
15(3):974–986. 79. Nahm N, Mee S, Marx G. Efficacy of management strategies for aromatase
51. Rogers LQ, Courneya KS, Verhulst S et al. Exercise barrier and task self-efficacy in inhibitor-induced arthralgia in breast cancer patients: a systematic review. Asia
breast cancer patients during treatment. Support Care Cancer 2006; 14(1):84–90. Pac J Clin Oncol 2017:1–9.
52. Courneya KS, Friedenreich CM. Physical activity and cancer control. Semin Oncol 80. Beckwee D, Leysen L, Meuwis K et al. Prevalence of aromatase inhibitor-induced
Nurs 2007; 23(4):242–252. arthralgia in breast cancer: a systematic review and meta-analysis. Support Care
53. Maiorana AJ, Williams AD, Askew CD et al. Exercise professionals with advanced Cancer 2017; 25(5):1673–1686.
clinical training should be afforded greater responsibility in pre-participation 81. Beck B, Day R, Singh M et al. Exercise and Sports Science Austrlalia (ESSA) posi-
exercise screening: a new collaborative model between exercise professionals tion statement on exercise prescription for the prevention and management of
and physicians. Sports Med 2018; 48(6):1293–1302. osteoporosis. J Sci Med Sport 2017; 20(5):438–445.
54. Santa Mina D, Langelier DM, Adams S et al. Exercise as part of routine cancer 82. Galvao DA, Taaffe DR, Spry N et al. Exercise preserves physical function in
care. Lancet Oncol 2018; 19(9):e433–e436. prostate cancer patients with bone metastases. Med Sci Sports Exerc 2018;
55. Buchan J, Janda M, Box R et al. A randomized trial on the effect of exer- 50(3):393–399.
cise mode on breast cancer-related lymphedema. Med Sci Sports Exerc 2016; 83. Carlin BI, Andriole GL. The natural history, skeletal complications, and man-
48(10):1866–1874. agement of bone metastases in patients with prostate carcinoma. Cancer 2000;
56. Buffart LM, Sweegers MG, May AM et al. Targeting exercise interventions to 88(12 Suppl):2989–2994.
patients with cancer in need: an individual patient data meta-analysis. J Natl 84. Berger AM, Mooney K, Alvarez-Perez A et al. Cancer-Related Fatigue, Version
Cancer Inst 2018; 110(11):1190–1200. 2.2015. J Natl Compr Canc Netw 2015; 13(8):1012–1039.
57. Chang JT, Morton SC, Rubenstein LZ et al. Interventions for the prevention of 85. Mustian KM, Alfano CM, Heckler C et al. Comparison of pharmaceutical, psy-
falls in older adults: systematic review and meta-analysis of randomised clinical chological, and exercise treatments for cancer-related fatigue: a meta-analysis.
trials. BMJ 2004; 328(7441):680. J Am Med Assoc 2017; 3(7):961–968.
58. Danhauer SC, Addington EL, Sohl SJ et al. Review of yoga therapy during cancer 86. Taaffe DR, Newton RU, Spry N et al. Effects of different exercise modali-
treatment. Support Care Cancer 2017; 25(4):1357–1372. ties on fatigue in prostate cancer patients undergoing androgen deprivation
59. Chandwani KD, Perkins G, Nagendra HR et al. Randomized, controlled trial of therapy: a year-long randomised controlled trial. Eur Urol 2017; 72(2):
yoga in women with breast cancer undergoing radiotherapy. J Clin Oncol 2014; 293–299.
32(10):1058–1065. 87. Zdenkowski N, Tesson S, Lombard J et al. Supportive care of women with
60. Kiecolt-Glaser JK, Bennett JM, Andridge R et al. Yoga’s impact on inflammation, breast cancer: key concerns and practical soluations. Med J Aust 2016;
mood, and fatigue in breast cancer survivors: a randomized controlled trial. J 205(10):471–475.
Clin Oncol 2014; 32(10):1040–1049. 88. Lenneman CG, Sawyer DB. Cardio-oncology: an update on cardiotoxicity of
61. Chang JI, Lam V, Patel MI. Preoperative pelvic floor muscle exercise and post- cancer-related treatment. Circ Res 2016; 118(6):1008–1020.
prostatectomy incontinence: a systematic review and meta-analysis. Eur Urol 89. Singh B, DiSipio T, Peake J et al. Systematic review and meta-analysis of the effcts
2016; 69(3):460–467. of exercise for those with cancer-related lymphoedema. Arch Phys Med Rehabil
62. Michie S, Abraham C, Whittington C et al. Effective techniques in healthy eat- 2016; 97(2):302–315.
ing and physical activity interventions: a meta-regression. Health Psychol 2009; 90. DiSipio T, Rye S, Newman B et al. Incidence of unilateral arm lymphoedema
28(6):690–701. after breast cancer: a systematic review and meta-analysis. Lancet Oncol 2013;
63. Scott JM, Zabor EC, Schwitzer E et al. Efficacy of exercise therapy on cardiores- 14(6):500–515.
piratory fitness in patients with cancer: a systematic review and meta-analysis. 91. Lindgren A, Dunberger G, Enblom A. Experiences of incontinence and pelvic floor
J Clin Oncol 2018; 36(22):2297–2305. muscle training after gynaecologic cancer treatment. Support Care Cancer 2017;
64. Licker M, Karenovics W, Diaper J et al. Short-term preoperative high-intensity 25(1):157–166.
interval training in patients awaiting lung cancer surgery: a randomized con- 92. Zimmer P, Baumann FT, Oberste M et al. Effects of exercise interventions and
trolled trial. J Thorac Oncol 2017; 12(2):323–333. physical activity behavior on cancer related cognitive impairments: a systematic
65. Jones LW, Eves ND, Peppercorn J. Pre-exercise screening and prescription guide- review. Biomed Res Int 2016 2016:1820954.
lines for cancer patients. Lancet Oncol 2010; 11(10):914–916. 93. Türk Y, Theel W, Kasteleyn MJ et al. High intensity training in obesity: a meta-
66. Williams S, French D. What are the most effective intervention techniques for analysis. Obesity Sci Pract 2017; 3(3):258–271.
changing physical activity self-efficacy and physical activity behavior and are 94. Hordern MD, Dunstan DW, Prins JB et al. Exercise prescription for patients with
they the same? Health Educ Res 2011; 26(2):308–322. type 2 diabetes and pre-diabetes: a position statement from Exercise and Sport
67. COSA Exercise Cancer Group Executive Committee. Clinical Oncology Society of Science Australia. J Sci Med Sport 2012; 15(1):25–31.
Australia position statement on exercise in cancer care. Med J Aust 2019; 210(1), 95. Bennell KL, Hinman RS. A review of the clinical evidence for exercise in
54-54 e51. osteoarthritis of the hip and knee. J Sci Med Sport 2011; 14(1):4–9.
68. Newton MJ, Hayes SC, Janda M et al. Safety, feasibility and effects of an individ- 96. Craft LL, VanIterson EH, Helenowski IB et al. Exercise Effects on Depressive
ualised walking intervention for women undergoing chemotherapy for ovarian Symptoms in Cancer Survivors: A Systematic Review and Meta-Analysis. Cancer
cancer: a pilot study. BMC Cancer 2011; 11:389. Epidemiol Biomarkers Prev 2012; 21(1):3–19.
69. Scott JM, Iyengar NM, Nilsen TS et al. Feasibility, safety, and efficacy of aero- 97. Stubbs B, Vancampfort D, Hallgren M et al. EPA guidance on physical activity as a
bic training in pretreated patients with metastatic breast cancer: a randomized treatment for severe mental illness: a meta-review of the evidence and Position
controlled trial. Cancer 2018; 124(12):2552–2560. Statement from the European Psychiatric Association (EPA), supported by the
70. Li T, Wei S, Shi Y et al. The dose–response effect of physical activity on can- International Organization of Physical Therapists in Mental Health (IOPTMH).
cer mortality: findings from 71 prospective cohort studies. Br J Sports 2016; Eur Psychiatry 2018; 54:124–144.
50:339–345. 98. Selig SE, Levinger I, Williams AD et al. Exercise & Sports Science Australia Position
71. Brown J, Damjanov N, Courneya KS et al. A randomized dose-response trial of Statement on exercise training and chronic heart failure. J Sci Med Sport 2010;
aerobic exercise and health-related quality of life in colon survivors. Psychoon- 13(3):288–294.
cology 2018; 27(4):1221–1228. 99. Sharman JE, Stowasser M. Australian association for exercise and sports sci-
72. Newton RU, Kenfield SA, Hart NH et al. Intense Exercise for Survival among ence position statement on exercise and hypertension. J Sci Med Sport 2009;
Men with Metastatic Castrate-Resistant Prostate Cancer (INTERVAL-GAP4): a 12(2):252–257.
multicentre, randomised, controlled phase III study protocol. BMJ Open 2018;
8(5):e022899.

Please cite this article in press as: Hayes SC, et al. The Exercise and Sports Science Australia position statement: Exercise medicine in
cancer management. J Sci Med Sport (2019), https://doi.org/10.1016/j.jsams.2019.05.003