Position statement summary
Sports medicine Cancer
Volume 209 - Issue 4

Clinical Oncology Society of Australia position statement on exercise in cancer care

Authors:  Prue Cormie, Morgan Atkinson, Lucy Bucci, Anne Cust, Elizabeth Eakin, Sandra Hayes, Alexandra L McCarthy, Andrew Murnane, Sharni Patchell and Diana Adams

Med J Aust 2018; 209 (4): 184-187. || doi: 10.5694/mja18.00199
Published online: 7 May 2018

Integrating exercise into routine cancer care: guidance for health professionals

Download PDF (163 KB)
Share: Share on Blue Sky Share on Facebook Share on LinkedIn Share by email

Abstract

Introduction: Clinical research has established exercise as a safe and effective intervention to counteract the adverse physical and psychological effects of cancer and its treatment. This article summarises the position of the Clinical Oncology Society of Australia (COSA) on the role of exercise in cancer care, taking into account the strengths and limitations of the evidence base. It provides guidance for all health professionals involved in the care of people with cancer about integrating exercise into routine cancer care.

Main recommendations: COSA calls for:

  • exercise to be embedded as part of standard practice in cancer care and to be viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment;
  • all members of the multidisciplinary cancer team to promote physical activity and recommend that people with cancer adhere to exercise guidelines; and
  • best practice cancer care to include referral to an accredited exercise physiologist or physiotherapist with experience in cancer care.

Changes in management as a result of the guideline: COSA encourages all health professionals involved in the care of people with cancer to:

  • discuss the role of exercise in cancer recovery;
  • recommend their patients adhere to exercise guidelines (avoid inactivity and progress towards at least 150 minutes of moderate intensity aerobic exercise and two to three moderate intensity resistance exercise sessions each week); and
  • refer their patients to a health professional who specialises in the prescription and delivery of exercise (ie, accredited exercise physiologist or physiotherapist with experience in cancer care).

The Clinical Oncology Society of Australia (COSA) is the peak national body representing multidisciplinary health professionals whose work encompasses cancer control and care. Its members are doctors, nurses, scientists and allied health professionals involved in the clinical care of people with cancer. COSA is affiliated with, and provides medical and scientific advice to, Cancer Council Australia. COSA has developed a statement outlining its position on the role of exercise in cancer care; the full statement is available at https://www.cosa.org.au/publications/position-statements/.

The term physical activity applies to any movement produced by skeletal muscles that requires the body to exert energy. Exercise is structured physical activity for the purpose of conditioning the body to improve health and fitness. To maximise the therapeutic potential of exercise, well established principles of training (including specificity, progression, overload, individualisation) should be applied and operationalised using the FITT formula: frequency (number of exercise sessions), intensity (how hard per session), time (session duration), and type (exercise modality).1,2 For a glossary of exercise terminology, see the Appendix.

Clinical research has established exercise as a safe and effective intervention to counteract many of the adverse physical and psychological effects of cancer and its treatment. To date, the strongest evidence exists for improving physical function (including aerobic fitness, muscular strength and functional ability), attenuating cancer-related fatigue, alleviating psychological distress and improving quality of life across multiple general health and cancer-specific domains.3-17 Emerging evidence highlights that regular exercise before, during and following cancer treatment decreases the severity of other adverse side effects and is associated with reduced risk of developing new cancers and comorbid conditions such as cardiovascular disease, diabetes and osteoporosis.3,4 Moreover, epidemiological research suggests that being physically active provides a protective effect against cancer recurrence, cancer-specific mortality and all-cause mortality for some types of cancer (research has predominantly focused on breast, colorectal and prostate cancers).3,18-27 These findings have set the scene for a number of clinical trials, which are currently underway to rigorously evaluate the effects of exercise on cancer survival.

The convincing body of epidemiological and clinical trial evidence on the benefits of exercise has led to the endorsement of exercise guidelines for people with cancer by major organisations internationally.28-33 These guidelines largely mirror guidelines for the general population. Despite this advice being widely disseminated by government and non-government cancer organisations, the majority of Australians with cancer do not meet these recommended targets.34-36 Reports indicate that 60–70% of people with cancer do not meet aerobic exercise guidelines and it is estimated that 80–90% do not meet resistance exercise guidelines.34-36 Thus, although many people with cancer have indicated a desire to participate in appropriately designed and supervised exercise programs,37-45 only a minority are engaging in sufficient levels of exercise.

The COSA position statement on exercise in cancer care outlines the Society’s position on exercise recommendations,28-33 taking into account the strengths and limitations of the epidemiological and clinical trials evidence base.

The key points are:

  • being physically active and exercising regularly are important for the health, function, quality of life and, potentially, survival of people with cancer;

  • the majority of people with cancer do not meet exercise recommendations;

  • people with cancer express a desire to become and to stay sufficiently active but need advice and support to do so; and

  • to maximise safety and therapeutic effect, exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with a focus on transitioning to ongoing self-managed exercise.

 

Methods

The development of the COSA position statement on exercise in cancer care was initiated by the COSA Exercise and Cancer Group. A proposal was submitted to the COSA Council (https://www.cosa.org.au/about-us/who-we-are/cosa-council/) to develop the statement based on the available scientific evidence and expert consensus. The position statement was prepared after a thorough review of the literature by a multidisciplinary group of COSA Exercise and Cancer Group members. The authorship group comprised experts across the fields of exercise physiology, physiotherapy, medical oncology, cancer nursing and public health. The draft position statement underwent review and revision with the broader COSA Exercise and Cancer Group (more than 200 professionals with an interest in exercise for people with cancer). Full consultation with all COSA members and relevant stakeholders was then undertaken, and responses and actions taken were detailed and revisions incorporated. The COSA Council then further reviewed the statement. Following revision, the final version was presented to the COSA Council for approval. After approval from the COSA Council, a number of relevant organisations were invited to endorse or support the position statement (Box 1).

Recommendations

Based on the available scientific evidence, COSA makes the following recommendations regarding exercise in cancer care (Box 2, Box 3 and Box 4).

Exercise should be embedded as part of standard practice in cancer care and viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment

The level of scientific evidence now available substantiates the inclusion of exercise as a component of routine cancer care.1-19 The body of scientific literature, including many randomised controlled trials involving thousands of cancer patients, provides evidence that exercise is an important adjunct therapy in the management of cancer.1-19 People with cancer who exercise experienced fewer or less severe adverse effects;1-19 thus, it is likely that incorporating exercise within the cancer treatment paradigm will reduce disease burden.3 While epidemiological evidence suggests that patients who exercise following a diagnosis of cancer have a lower relative risk of cancer mortality and recurrence,3,20-27 randomised controlled trial data are required to determine the effect of exercise on survival outcomes.

All members of the multidisciplinary cancer team should promote physical activity and recommend people with cancer adhere to exercise guidelines

COSA calls for evidence-based exercise guidelines28-33 to be implemented by all health professionals involved in the care of people with cancer. Specifically, all members of the cancer care team should advise their patients to:

  • avoid inactivity and be as physically active as current abilities and conditions allow; and

  • progress towards and, once achieved, maintain participation in at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic exercise each week, and two to three resistance exercise sessions each week involving moderate to vigorous intensity exercises targeting the major muscle groups.

 

In line with evidence-based guidelines,28-33 COSA identifies that these recommendations should be tailored to the individual’s abilities, noting that specific exercise programming adaptations may be required based on disease- and treatment-related adverse effects, anticipated disease trajectory and the patient’s health status.

Best practice cancer care should include referral to an accredited exercise physiologist or physiotherapist with experience in cancer care

COSA recognises that accredited exercise physiologists and physiotherapists, as university qualified allied health professionals specialising in the prescription and delivery of exercise, are the most appropriate practitioners to implement exercise guidelines with cancer patients. While not all people with cancer will require ongoing supervision, these practitioners will allow for exercise to be prescribed in line with evidence-based guidelines.28-33 Specifically, exercise physiologists and physiotherapists with experience in cancer care will appropriately tailor exercise recommendations to the individual needs of each patient. Such practitioners are also trained to educate patients in behaviour change techniques to allow for positive long term exercise behaviour.

Box 1 – Endorsing and supporting organisations

  • The Clinical Oncology Society of Australia position statement on exercise in cancer care is a stand-alone document, the content of which is not influenced by any other authority.
  • The statement is endorsed by the Australian Physiotherapy Association, Cancer Council Australia, Exercise and Sports Science Australia, and Medical Oncology Group of Australia.
  • A range of other organisations also support the position statement: Australasian Gastro-Intestinal Trials Group; Australasian Leukaemia and Lymphoma Group; Australasian Lung Cancer Trials Group; Australian and New Zealand Urogenital and Prostate Cancer Trials Group; Australasian Sarcoma Study Group; Australian and New Zealand Children’s Haematology/Oncology Group; Australia and New Zealand Melanoma Trials Group; Beyond Five; Breast Cancer Network Australia; Cancer Nurses Society of Australia; Cooperative Trials Group for Neuro-Oncology; Counterpart; Lung Foundation Australia; Ovarian Cancer Australia; Palliative Care Clinical Studies Collaborative; Primary Care Collaborative Cancer Clinical Trials Group; Prostate Cancer Foundation of Australia; Psycho-Oncology Co-operative Research Group; Royal Australasian College of Physicians; and Trans-Tasman Radiation Oncology Group.

Box 2 – The Clinical Oncology Society of Australia calls for:

  • Exercise to be embedded as part of standard practice in cancer care and viewed as an adjunct therapy that helps counteract the adverse effects of cancer and its treatment.
  • All members of the multidisciplinary cancer team to promote physical activity and recommend people with cancer adhere to exercise guidelines.
  • Best practice cancer care to include referral to an accredited exercise physiologist or physiotherapist with experience in cancer care.

Box 3 – Clinical Oncology Society of Australia position on exercise in cancer care

 

  • All people with cancer should avoid inactivity and return to normal daily activities as soon as possible following diagnosis (ie, be as physically active as current abilities and conditions allow).
  • All people with cancer should progress towards and, once achieved, maintain participation in:
    • at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic exercise (eg, walking, jogging, cycling, swimming) each week; and
    • two to three resistance exercise (eg, lifting weights) sessions each week involving moderate to vigorous intensity exercises targeting the major muscle groups.
  • Exercise recommendations should be tailored to the individual’s abilities, noting that specific exercise programming adaptations may be required for people with cancer based on disease- and treatment-related adverse effects, anticipated disease trajectory and their health status.*
  • Accredited exercise physiologists and physiotherapists are the most appropriate health professionals to prescribe and deliver exercise programs to people with cancer.†
  • All health professionals involved in the care of people with cancer have an important role in promoting these recommendations.

 

* The Clinical Oncology Society of Australia position statement contains general principles only and should not be used as a substitute for individual exercise prescription. Consideration of exercise safety for an individual should be assessed by a health professional with knowledge of cancer, before exercise commencement. † Services provided by accredited exercise physiologists and physiotherapists are eligible for subsidies through Medicare and private health insurers. An extensive number of exercise physiologists and physiotherapists are based in the community and can be located using online search functions of the respective accrediting bodies: exercise physiologists (https://www.essa.org.au/find-aep/); physiotherapists (www.physiotherapy.asn.au/apawcm/controls/FindAPhysio.aspx). Effective exercise prescriptions can be delivered across a variety of settings including hospital, cancer treatment centre, community and home (ie, self-managed).

Box 4 – Best practice cancer care

The Clinical Oncology Society of Australia encourages all health professionals involved in the care of people with cancer to:
  • discuss the role of exercise in cancer recovery;
  • recommend their patients adhere to the exercise guidelines; and
  • refer their patients to a health professional who specialises in the prescription and delivery of exercise (ie, accredited exercise physiologist or physiotherapist with experience in cancer care).

Authors

  • Prue Cormie1
  • Morgan Atkinson2
  • Lucy Bucci3
  • Anne Cust4,5
  • Elizabeth Eakin6
  • Sandra Hayes7
  • Alexandra L McCarthy8
  • Andrew Murnane3
  • Sharni Patchell3
  • Diana Adams9
  • 1. Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC
  • 2. Youth Cancer Services South Australia and Northern Territory, Adelaide, SA
  • 3. Peter MacCallum Cancer Centre, Melbourne
  • 4. Cancer Epidemiology and Prevention Research Group, University of Sydney, Sydney, NSW
  • 5. Melanoma Institute Australia, Sydney, NSW
  • 6. University of Queensland, Brisbane, QLD
  • 7. Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD
  • 8. University of Auckland, Auckland, NZ
  • 9. Macarthur Cancer Therapy Centre, South Western Sydney Local Health District, Sydney, NSW

Correspondence: prue.cormie@acu.edu.au

Competing interests

No relevant disclosures.

Acknowledgements

This position statement was developed with the support of the COSA Council and Exercise and Cancer Group. We acknowledge the feedback provided by the COSA members and affiliated organisations throughout the national consultation process. We also acknowledge the contribution of COSA staff who assisted in the development of the position statement. Anne Cust is supported by National Health and Medical Research Council and Cancer Institute NSW Career Development Fellowships. Sandra Hayes receives fellowship funding from Cancer Council Queensland.

References

Linked content

  • MJA Letter: Clinical Oncology Society of Australia position statement on exercise in cancer care

  • MJA Letter: Clinical Oncology Society of Australia position statement on exercise in cancer care

  • MJA Podcast: Associate Professor Prue Cormie

View this article on Wiley Online Library

More like this

Sports medicine Perspective 3 November 2025 Free

Mild traumatic brain injury and concussion and persisting post‐concussion symptoms: new guidelines to support evidence‐based assessment and management in Australia and Aotearoa New Zealand

Karen M Barlow, Jennie L Ponsford, Alice Theodom, Gill Cowen, Gavin A Davis, Vicki Anderson, Franz E Babl, David Cole, Jennifer Cullen, Stuart R Dalziel, Melinda Fitzgerald, Howard Flavell, Caroline Yates, Rebecca Kimble, John H Olver, Rhonda Orr, Mark Ralfe, Michael Rose, Nick Rushworth, Julia Treleaven, Gary Browne, Nathan Delang, Sarah Harris, Gary Mitchell, Sean Tweedy

View more