Scientific evidences show that people living with and surviving cancer may practice physical activity with several benefits and without particular side effects if type, timing and intensity are targeted on their clinical status. Physical exercise may prevent or reduce cancer-related fatigue before, during and after therapy. This commentary would like to show that despite these evidences, less is still known about effectiveness of physical exercises programs since hospitalization. Therefore, reporting an Italian example of multidisciplinary model of rehabilitation and educational program, started during hospitalization in Oncology ward and continued at discharge, we would like to underline the importance, to promote a safe life styles to increase the quality of life and not only the amount of cancer patients.
breast cancer patients, cancer-related fatigue, colon-rectus cancer Patients, hospitalization, physical exercise, rehabilitation
As reported by the EUROCARE-5 study, survival for patients with cancer increased from 1999-2001 to 2005-2007 despite some differences across Europe with lowest survival observed in Eastern Europe [1-3]. In Italy, an increasing survival of about 20% is registered after cancer diagnosis in the last years , on the basis of the information from the Italian Association of Cancer Registries (AIRTUM)  database [6,7]. Despite of the increasing survival, about 4,9% of the Italian population has a cancer diagnosis and on 365.800 new diagnoses in 2016, the breast and the colon localizations are the most frequent, with 52.000 new diagnoses for the colon-rectus cancer and 50.000 new diagnoses for breast cancer . In this scenario, cancer networks and multidisciplinary approach may play a key role , including rehabilitation and physical exercises programs for people living with and surviving cancer . The goal, today, is to increase the quality of life and not only the amount of this in cancer patients .
We know that disability, cardiovascular disease risk, morbidity, and mortality are influenced by several physical benefits of exercise, including peak oxygen consumption, functional capacity, muscle strength and lean mass, cardiovascular risk factors, and bone health. There are many evidences that physical activity have a positive impact on physiology, body composition, physical functions, psychological outcomes, and quality of life in cancer patients during therapy [11-14], after completion of cancer-related main treatment [15,16], after and during adjuvant treatment  and to reduce long-term side effects , especially in breast cancer  and colorectal cancer patients . Those benefits are not dependent on cancer type, in particular cardiorespiratory and fatigue improvements following rehabilitative exercise .
Exercise therapy is effective for decreasing pain in patients during and following cancer treatment [22,23], and to improve quality of life during active treatment and for survivors [11,13,14].
Physical exercise may prevent or reduce cancer-related fatigue (CRF) before, during and after therapy [24-27], but less is known about effectiveness of physical exercises programs for CRF in advanced cancer patients . Exercise during cancer therapy probably results in less fatigue and improved physical fitness and resistance exercises programs appeared to contribute to maintain quality of life. Both aerobic and resistance exercises can be regarded as beneficial for patients with therapy-related side effects. For those reasons clinicians should prescribe exercise, eventually in associations with psychological interventions, as first-line treatments for CRF . Nevertheless, further research is required to determine the optimal type, intensity, and timing of an exercise intervention [30-32].
The existing reviews and guidelines on physical activity and rehabilitation are generics, the target is to avoid inactivity, some benefits are evident for regular sessions and for moderate intensity exercise , an additional benefit of multi-dimensional over mono-dimensional rehabilitation was not clearly found, home-based programs are also effective and nevertheless a favourable cost-effectiveness is shown. Further research is needed to develop more personalized programs that should take into consideration interests and preferences of patients to facilitate optimal interventions [23,34-40].
Although it is known in the literature, as stated earlier, that people living with and surviving cancer may practice physical activity with several benefits and without particular side effects if type, timing and intensity are targeted on their clinical status. However, many patients are inactive and do not meet exercise recommendations. Clinicians should promote exercise since hospitalization, discussing with patients the benefits of physical activity and implementing educational programs to bridge the gap between research and practice [37,41-43].
On that basis, the Rehabilitation Service of Parma University-Hospital, in collaboration with the Clinical Oncology Unit, is proposing a model of rehabilitation and promotion of life styles for cancer patients starting from hospitalization in Oncology ward. It is an inpatients rehabilitation project based on an aerobic and resistance exercises program supervised by a physical therapist specialized in oncological rehabilitation and dedicated to this activity. The goal of the intervention is to promote an educational program of good life style in cancer patients by explaining the benefits of physical activity and by training the patients and the caregiver to perform the exercises correctly. At the discharge a personalized home-based exercise program is explained and described to patient and caregivers, according to the one performed during hospitalization.
The rehabilitation and promotion of life styles program is conducted according to international standards of good practice, such as the Declaration of Helsinki and Good Clinical Practice.
A physical and rehabilitation specialist selected patients from Clinical Oncology ward of Parma University Hospital, with different type of cancer and in different phases of treatment, aged between 18 and 70 years, without clinical complications that could interfere with physical activity (e.g. sepsis, fever, immunocompromised patients) or apparent cognitive impairment, with a recovery time of at least 5 days. Patients before starting the rehabilitation program had to accept to participate at an informational interview and completion of informed consent
During the first 2 months of program, 65 patients were hospitalized in Clinical Oncology ward. 43.08% were male (n=28) and the 56.92% were female (n=37), 28 patients did not meet inclusion criteria, 14 (the 38%) refused to participate to the program. Twenty-three patients were recruited for the study, but 12 dropped out because of clinical complications. Only 11 patients completed the program during two months of recruitment (7 male: mean age 64 ± 11.5 SD years; 4 female: mean age 69 ± 5.8 SD years).
After history taking and first physical examination, patients were divided into 2 groups according to the disability: in group A were allocated patients able to walk, in group B patients that for different clinical conditions were not able to walk.
Both groups were evaluated at admission with the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) version 3.0 questionnaire to assess quality of life [44,45], Mini Mental State Examination (MMSE) to assess cognitive functioning , Modified Barthel Index (BIM) to assess independence and disability , Karnofsky Performance Status scale (KPS) to quantify the functional status , handgrip strength was assessed with Jamar dynamometer  and Numering Rating Scale (NRS) for pain and fatigue. Two-minute walking test (2MWT) [50,51] and Short Physical Performance Battery (SPPB) to test physical performance and balance [52,53] were used only for group A and Trunk Control Test (TCT) only for group B . At discharge patients were assessed with a specific satisfaction questionnaire concerning rehabilitation treatment received and BIM, KPS, NRS, handgrip test. SPPB, 2MWT and TCT were assessed depending on group.
The 5-session exercises program was initiated the day after the first physical examination and baseline evaluation, according with clinical conditions of the patients. Sessions lasting approximatively 45 to 60 minutes, depending on patient ability and on group and occurred every day. Vital signs were assessed before and after each session, at the end of the session even NRS for pain and fatigue and presence of dyspnoea were assessed. Participants were allowed to make up sessions missed due to clinical complications as long as the entire exercise program was completed. During a 10-minute warm-up period, patients performed range of motion and stretching exercises for the trunk and lower and upper limbs. Participants then completed 15 minutes of aerobic exercise on an arm bike. For the strength training part of this exercises program, patients performed 3 sets of 10 repetitions of 6 different exercises (e.g. 3 lower extremity and 3 upper extremity movements), for a total of approximatively 20 to 30 minutes, exercises were modified or discontinued for patients that were unable to complete them. A cool down period of 1 minute followed every repetition. Then only participants of group A completed another 15 minutes of aerobic exercise session with walk at middle speed on a flat, straight and hard surface path. A cool down period of 2 to 5 minutes followed the aerobic session on both, the bike and the walk.
At discharge, it is expected that a restricted group of patients with breast or colon cancer after adjuvant treatment, in good clinical conditions, will be trained for a personalized exercises program in a professional gym. They will be evaluated by a Sport Medicine Specialist for the best physical performance for achieving the goal level of intensity for the aerobic exercise (heart rate between 70 and 85% of their maximum) and the strength of major muscle groups associated with performing activities of daily living (the maximal amount of weight that each muscle group can move through the available range of motion). On the basis of those evaluations they will be trained by specialized personnel for a personalized exercises program of 12-session, each lasting approximately 60 minutes, occurred twice weekly over the course of 1 month. After this training, patients should continue their physical activity in a gym or with an home-based program. This will be a rehabilitation clinical model based on physical exercise that start in the hospital and continues for outpatients to support survivors in prevention of recurrences and managing of cancer-related long term complications.
For all participants (inpatients and outpatients) a follow-up at 6 months with EORTC QLQ-C30 is expected, to assess quality of life after discharge and to notice if patients are attending their physical activity with home-based program or in a gym.
To assess variation in the collected information between admission, discharge and a 6 month Follow-up, an Anova Repeated Measure will be performed.
Nowadays no patients have completed the entire program. The small sample investigated (n=11) during the 2 months of recruitment does not allow to statistically demonstrate the effectiveness of the structured exercises and promotion of life styles program for cancer patients. However, some improvements in physical performance for both group A and group B patients were observed.
The group A data reported an improvements in the distance in meters performed during 2MWT and in the energy produced during arm bike session between admission and discharge. Furthermore an improvement of fatigue has been observed. Group B has shown an improvement in number of repetitions for the strength training part of this exercise program, an improvement of pain, fatigue and of SPPB.
The survey relatively to usefulness and satisfaction to the treatment, has allowed us to detect a positive judgment, to support the model of inpatients treatment proposed.
The aim of the Italian experience is to evaluate the effectiveness of a brief program of inpatients rehabilitation and promotion of life styles (at least 5 days) in the Oncology ward of Parma University Hospital. Preliminary data observed represented a positive trend for both the participants’ performance and satisfaction concerning the treatment proposed.
As stated earlier, the small sample investigated (n=11) during the 2 months of recruitment does not allow to statistically demonstrating the effectiveness of the structured exercises and promotion of life styles program for cancer patients. Nevertheless this experience is different from those reported in the literature, in our knowledge, for the presence of a therapeutic program for an inpatient limited in time. Furthermore we have proposed a structured, reproducible and easy exercises protocol that according to current clinical and scientific recommendation could be compared with other experiences.
Considering the degree of comorbid disease and health status of inpatients in the Oncology ward of Parma University Hospital, we supposed an adherence rate of 70% to be an acceptable goal. Our target during the 2-year study period is approximately 100 patients. It will be necessary to continue the study to evaluate the efficacy of the model proposed in the short term with the inpatients assessment. In medium and long term the effectiveness of our rehabilitation model will be evaluated with follow-up and with the observation of the personalized exercises program in the professional gym for a restricted group of patients with breast and colon cancer after adjuvant treatment.
Evidences shown that physical activity have a positive impact on physical functions, psychological outcomes, and quality of life for patients living with and surviving cancer [11-18] especially in breast cancer  and colorectal cancer survivors .
If the results of this study are positive it will be possible to implement current local clinical practice for cancer patients, by providing a rehabilitation and clinical care pathway based on physical exercise starting during hospitalization and continuing outpatients after adjuvant treatment. This model of rehabilitation is in accordance whit the Evidence Based Medicine and Practice.
We are grateful to all the multidisciplinary team of Parma who worked to produce the on-going rehabilitation program and to all patients that accepted to participate. Special thanks are due to Dr. Alberto Anedda, Director of the Sport Medicine Unit, NHS Local Agency of Parma, Italy, for having contributed to continue, for the first time in Parma, a physical exercise program of the cancer patients, also after discharge.
The Parma experience is a No Profit Research. However we have to be grateful to the not-for-profit association A.VO.PRO.RI.T. (Associazione Volontaria Promozione Ricerca Tumori), for Financial support.
1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data: FR, FeP, VS, CC, VF, FaP, RB
2) drafting the article or revising it critically for important intellectual content: FR, FeP, VS, CC, VF, FaP, RB
3) final approval of the version to be published: FR, FeP, VS, CC, VF, FaP, RB
4) agreement to act as guarantor of the work (ensuring that questions related to any part of the work are appropriately investigated and resolved): FR, FeP, VS, CC, VF, FaP, RB
2021 Copyright OAT. All rights reserv
The authors declare that they have no competing interests
- Holleczek B, Rossi S, Domenic A, Innos K, Minicozzi P, et al. (2015) On-going improvement and persistent differences in the survival for patients with colon and rectum cancer across Europe 1999-2007-Results from the EUROCARE-5 study. Eur J Cancer S0959-8049(15)00704-2. [Crossref]
- Sant M, Chirlaque Lopez MD, Agresti R, Sánchez Pérez MJ, Holleczek B, et al. (2015) EUROCARE-5 Working Group. Survival of women with cancers of breast and genital organs in Europe 1999-2007: results of the EUROCARE-5 study. Eur J Cancer S0959-8049(15)00702-9. [Crossref]
- Rossi S, Baili P, Capocaccia R, Caldora M, Carrani E, et al. (2015) The EUROCARE-5 study on cancer survival in Europe 1999-2007: database, quality checks and statistical analysis methods. Eur J Cancer S0959-8049(15)00776-5. [Crossref]
- Dal Maso L, Buzzoni C, Guzzinati S, Crocetti E, AIRTUM Working Group (2016) Italy 2015: 3 million Italians are living after a cancer diagnosis, both incidence and mortality are decreasing. Epidemiol Prev 40: 75. [Crossref]
- AIOM/AIRTUM (2016) I numeri del cancro in Italia. Roma: Il Pensiero Scientifico Editore.
- AIRTUM Working Group, Busco S, Buzzoni C, Mallone S, Trama A, et al. (2016) Italian cancer figures--Report 2015: The burden of rare cancers in Italy. Epidemiol Prev 40(1 Suppl 2): 1-120. [Crossref]
- AIRTUM Working Group (2014) Italian cancer figures, report 2014: Prevalence and cure of cancer in Italy. Epidemiol Prev 38: 1-122. [Crossref]
- Pinto C, Mangone L (2016) [Epidemiology of cancer in Italy: from real data to the need for cancer networks. Recenti Prog Med 107: 505-506. [Crossref]
- Scott DA, Mills M, Black A, Cantwell M, Campbell A, et al. (2013) Multidimensional rehabilitation programmes for adult cancer survivors. Cochrane Database Syst Rev 28: CD007730. [Crossref]
- Schmitz KH, Stout NL, Andrews K, Binkley JM, Smith RA (2012) Prospective evaluation of physical rehabilitation needs in breast cancer survivors: a call to action. Cancer 118(8 Suppl): 2187-90.
- Buffart LM, Kalter J, Sweegers MG, Courneya KS, Newton RU, et al. (2017) Effects and moderators of exercise on quality of life and physical function in patients with cancer: An individual patient data meta-analysis of 34 RCTs. Cancer Treat Rev 52: 91-104.
- Van Moll CC, Schep G, Vreugdenhil A, Savelberg HH, Husson O (2016) The effect of training during treatment with chemotherapy on muscle strength and endurance capacity: A systematic review. Acta Oncol 55: 539-546. [Crossref]
- Mishra SI, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, et al. (2012a) Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev 8: CD008465. [Crossref]
- Mishra SI, Scherer RW, Geigle PM, Berlanstein DR, Topaloglu O, et al. (2012b) Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Syst Rev 8:CD007566. [Crossref]
- McClellan R (2013) Exercise programs for patients with cancer improve physical functioning and quality of life. J Physiother 59: 57. [Crossref]
- Fong DY, Ho JW, Hui BP, Lee AM, Macfarlane DJ, et al. (2012) Physical activity for cancer survivors: meta-analysis of randomised controlled trials. BMJ 344: e70.
- Mishra SI, Scherer RW, Snyder C, Geigle P, Gotay C (2015) The effectiveness of exercise interventions for improving health-related quality of life from diagnosis through active cancer treatment. Oncol Nurs Forum 42: E33-E53. [Crossref]
- Casla S, Hojman P, Márquez-Rodas I, López-Tarruella S, Jerez Y, et al. (2015) Running away from side effects: physical exercise as a complementary intervention for breast cancer patients. Clin Transl Oncol 17: 180-196. [Crossref]
- Kirkham AA, Bland KA, Sayyari S, Campbell KL, Davis MK (2016) Clinically Relevant Physical Benefits of Exercise Interventions in Breast Cancer Survivors. Curr Oncol Rep 18: 12. [Crossref]
- Devin JL, Sax AT, Hughes GI, Jenkins DG, Aitken JF, et al. (2016) The influence of high-intensity compared with moderate-intensity exercise training on cardiorespiratory fitness and body composition in colorectal cancer survivors: a randomised controlled trial. J Cancer Surviv 10: 467-479. [Crossref]
- Repka CP, Peterson BM, Brown JM, Lalonde TL, Schneider CM, et al. (2014) Cancer type does not affect exercise-mediated improvements in cardiorespiratory function and fatigue. Integr Cancer Ther 13: 473-481. [Crossref]
- Nijs J, Leysen L, Pas R, Adriaenssens N, Meeus M, et al. (2016) Treatment of pain following cancer: applying neuro-immunology in rehabilitation practice. Disabil Rehabil 15: 1-8.
- Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvão DA, et al. (2010) American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc 42: 1409-1426. [Crossref]
- Gerber LH (2017) Cancer-Related Fatigue: Persistent, Pervasive, and Problematic. Phys Med Rehabil Clin N Am 28: 65-88. [Crossref]
- Scott K, Posmontier B (2017) Exercise Interventions to Reduce Cancer-Related Fatigue and Improve Health-Related Quality of Life in Cancer Patients. Holist Nurs Pract 31: 66-79. [Crossref]
- Tian L, Lu HJ, Lin L, Hu Y (2016) Effects of aerobic exercise on cancer-related fatigue: a meta-analysis of randomized controlled trials. Support Care Cancer 24: 969-983. [Crossref]
- van Vulpen JK, Peeters PH, Velthuis MJ, van der Wall E, May AM (2016) Effects of physical exercise during adjuvant breast cancer treatment on physical and psychosocial dimensions of cancer-related fatigue: A meta-analysis. Maturitas 85: 104-111. [Crossref]
- Lowe SS, Tan M, Faily J, Watanabe SM, Courneya KS (2016) Physical activity in advanced cancer patients: a systematic review protocol. Syst Rev 11: 43. [Crossref]
- Mustian KM, Alfano CM, Heckler C, Kleckner AS, Kleckner IR, et al. (2017) Comparison of Pharmaceutical, Psychological, and Exercise Treatments for Cancer-Related Fatigue: A Meta-analysis. JAMA Oncol. [Crossref]
- Lipsett A, Barrett S, Haruna F, Mustian K, O'Donovan A (2017) The impact of exercise during adjuvant radiotherapy for breast cancer on fatigue and quality of life: A systematic review and meta-analysis. Breast 32: 144-155. [Crossref]
- Furmaniak AC, Menig M, Markes MH (2016) Exercise for women receiving adjuvant therapy for breast cancer. Cochrane Database Syst Rev 9: CD005001.
- Schmidt ME, Wiskemann J, Armbrust P, Schneeweiss A, Ulrich CM, et al. (2015) Effects of resistance exercise on fatigue and quality of life in breast cancer patients undergoing adjuvant chemotherapy: A randomized controlled trial. Int J Cancer 137: 471-480. [Crossref]
- Smith TM, Broomhall CN, Crecelius AR (2016) Physical and Psychological Effects of a 12-Session Cancer Rehabilitation Exercise Program. Clin J Oncol Nurs 20: 653-659. [Crossref]
- Lahart IM, Metsios GS, Nevill AM, Kitas GD, Carmichael AR (2016) Randomised controlled trial of a home-based physical activity intervention in breast cancer survivors. BMC Cancer 16: 234. [Crossref]
- Buffart LM, Galvão DA, Brug J, Chinapaw MJ, Newton RU (2014) Evidence-based physical activity guidelines for cancer survivors: current guidelines, knowledge gaps and future research directions. Cancer Treat Rev 40: 327-340. [Crossref]
- Zopf EM, Baumann FT, Pfeifer K (2014) Physical activity and exercise recommendations for cancer patients during rehabilitation. Rehabilitation (Stuttg) 53: 2-7. [Crossref]
- Bourke L, Homer KE, Thaha MA, Steed L, Rosario DJ, et al. (2013) Interventions for promoting habitual exercise in people living with and beyond cancer. Cochrane Database Syst Rev 9: CD010192. [Crossref]
- Harris SR, Schmitz KH, Campbell KL, McNeely ML (2012) Clinical practice guidelines for breast cancer rehabilitation: syntheses of guideline recommendations and qualitative appraisals. Cancer 118(8 Suppl): 2312-2324. [Crossref]
- Mewes JC, Steuten LM, Ijzerman MJ, van Harten WH (2012) Effectiveness of multidimensional cancer survivor rehabilitation and cost-effectiveness of cancer rehabilitation in general: a systematic review. Oncologist 17: 1581-1593. [Crossref]
- Wolin KY, Schwartz AL, Matthews CE, Courneya KS, Schmitz KH (2012) Implementing the exercise guidelines for cancer survivors. J Support Oncol 10: 171-177. [Crossref]
- Cormie P, Lamb S, Newton RU, Valentine L, McKiernan S, et al. (2017) Implementing exercise in cancer care: study protocol to evaluate a community-based exercise program for people with cancer. BMC Cancer 17: 103. [Crossref]
- Yang DD, Hausien O, Aqeel M, Klonis A, Foster J, et al. (2017) Physical activity levels and barriers to exercise referral among patients with cancer. Patient Educ Couns S0738-3991(17)30063-0. [Crossref]
- Bourke L, Homer KE, Thaha MA, Steed L, Rosario DJ, et al. (2014) Interventions to improve exercise behaviour in sedentary people living with and beyond cancer: a systematic review. Br J Cancer 110: 831-841. [Crossref]
- Giesinger JM, Kieffer JM, Fayers PM, Groenvold M, Petersen MA, et al. (2016) EORTC Quality of Life Group. Replication and validation of higher order models demonstrated that a summary score for the EORTC QLQ-C30 is robust. J Clin Epidemiol 69: 79-88. [Crossref]
- Apolone G, Filiberti A, Cifani S, Ruggiata R, Mosconi P (1998) Evaluation of the EORTC QLQ-C30 questionnaire: a comparison with SF-36 Health Survey in a cohort of Italian long-survival cancer patients. Ann Oncol 9: 549-557. [Crossref]
- Folstein MF, Folstein SE, McHugh PR (1975) "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12: 189-198. [Crossref]
- Galeoto G, Lauta A, Palumbo A, Castiglia SF, Mollica R, et al. (2015) The Barthel Index: Italian Translation, Adaptation and Validation. Int J Neurol Neurother 2: 028.
- Schag CC, Heinrich RL, Ganz PA (1984) Karnofsky performance status revisited: reliability, validity, and guidelines. J Clin Oncol 2: 187-193. [Crossref]
- Roberts HC, Denison HJ, Martin HJ, Patel HP, Syddall H, et al. (2011) A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach. Age Ageing 40: 423-429. [Crossref]
- Brooks D, Parsons J, Tran D, Jeng B, Gorczyca B, et al. (2004) The two-minute walk test as a measure of functional capacity in cardiac surgery patients. Arch Phys Med Rehabil 85: 1525-1530. [Crossref]
- Gloeckl R, Teschler S, Jarosch I, Christle JW, Hitzl W, et al. (2016) Comparison of two- and six-minute walk tests in detecting oxygen desaturation in patients with severe chronic obstructive pulmonary disease - A randomized crossover trial. Chron Respir Dis. [Crossref]
- Pavasini R, Guralnik J, Brown JC, di Bari M, Cesari M, et al. (2016) Short Physical Performance Battery and all-cause mortality: systematic review and meta-analysis. BMC Med 14: 215. [Crossref]
- Verweij NM, Schiphorst AH, Pronk A, van den Bos F, Hamaker ME (2016) Physical performance measures for predicting outcome in cancer patients: a systematic review. Acta Oncol 55: 1386-1391. [Crossref]
- Sheikh K, Smith DS, Meade TW, Brennan PJ, Ide L (1980) Assessment of motor function in studies of chronic disability. Rheumatol Rehabil 19: 83-90. [Crossref]