Exercise-Based Oncology Rehabilitation: Leveraging the

Cardiac Rehabilitation Model

Kim L. Dittus, MD, PhD1, Susan G. Lakoski, MD, MS1, Patrick D. Savage, MS2, Nathan

Kokinda, MS3, Michael Toth, PhD4, Diane Stevens, PT, BS2, Kimberly Woods, PT, MEd2,

Patricia O’Brien, MD5, and Philip A. Ades, MD1

1Department of Internal Medicine, Vermont Center on Behavior and Health, University of

Vermont, Bulington, VT

2Fletcher Allen Health Care, Bulington, VT

3Department of Rehabilitation and Movement Science, University of Vermont, Bulington, VT

4Departments of Internal Medicine and Molecular Physiology and Biophysics, University of

Vermont, Bulington, VT

5Department of Internal Medicine, University of Vermont, Bulington, VT

Abstract

PURPOSE—The value of exercise and rehabilitative interventions for cancer survivors is

increasingly clear and oncology rehabilitation programs could provide these important

interventions. However, a pathway to create oncology rehabilitation has not been delineated.

Community-based cardiac rehabilitation (CR) programs staffed by health care professionals with

experience in providing rehabilitation and secondary prevention services to individuals with

coronary heart disease are widely available and provide a potential model and location for

oncology rehabilitation programs. Our purpose is to outline the rehabilitative needs of cancer

survivors and demonstrate how oncology rehabilitation can be created using a cardiac

rehabilitation model.

METHODS—We identify the impairments associated with cancer and its therapy that respond to

rehabilitative interventions. Components of the CR model that would benefit cancer survivors are

described. An example of an oncology rehabilitation program using a CR model is presented.

RESULTS—Cancer survivors have impairments associated with cancer and its therapy that

improve with rehabilitation. Our experience demonstrates that effective rehabilitation services can

be provided utilizing an existing CR infrastructure. Few adjustments to current cardiac

rehabilitation models would be needed to provide oncology rehabilitation. Preliminary evidence

suggests that cancer survivors participating in an oncology rehabilitation program experience

improvements in psychological and physiologic parameters.

Correspondence: Kim Dittus, MD, PhD, University of Vermont, Given E-214, 89 Beaumont Ave., Burlington, VT 05405.

(kim.dittus@vtmednet.org).

Conflict of Interest: None declared.

All authors have read and approved the manuscript.

NIH Public Access

Author Manuscript

J Cardiopulm Rehabil Prev. Author manuscript; available in PMC 2016 March 01.

Published in final edited form as:

J Cardiopulm Rehabil Prev. 2015 ; 35(2): 130–139. doi:10.1097/HCR.0000000000000091.

NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript

CONCLUSIONS—Utilizing the CR model of rehabilitative services and disease management

provides a much needed mechanism to bring oncology rehabilitation to larger numbers of cancer

survivors.

Keywords

cardiac rehabilitation; cancer survivors; oncology rehabilitation

Currently there are over 13 million cancer survivors in the United States with 18 million

expected by 2022.1

Individuals who undergo cancer therapy experience declines in fitness2

,

strength3

, and physical function4

. Cancer and associated therapies result in local symptoms,

such as range of motion deficits and lymphedema, as well as systemic impacts including

fatigue, deconditioning and pain syndromes.5

Survivors of some types of cancers are also at

increased risk for the development of cardiovascular disease.6,7

The unintended

consequences of cancer treatments can be ameliorated by rehabilitative interventions.

Exercise interventions have documented improvements in aerobic fitness, strength and other

persistent effects of cancer therapy. Additionally, epidemiologic evidence is accumulating

that physical activity improves cancer related outcomes such as decreasing recurrence and

increasing survival although randomized controlled trial data are lacking.8,9,10 Given the

proportion of individuals living with a cancer diagnosis oncology rehabilitation programs

should become a standard component of cancer survivor care.

Cardiac rehabilitation (CR) is standard of care for individuals after a cardiac event. Exercise

is the cornerstone of CR but risk factor management, stress reduction, behavioral and

nutritional counseling, and tobacco cessation are also core components.11 CR professionals

have the expertise required to provide monitored exercise, lifestyle interventions and other

rehabilitative services to a wide variety of patients, including cancer survivors.12 In addition

to reductions in cardiac and overall mortality13 and a decreased rate of cardiac

rehospitalizations, CR participation is associated with improvements in exercise capacity14

and measures of quality of life.15

Cardiac rehabilitation programs are widely available in the United States. With a focus on

secondary disease prevention, decreasing mortality and morbidity, improving physical

function and quality of life, CR provides an ideal framework for developing comprehensive

oncology rehabilitation programs. The goal of this article is to outline the needs of cancer

survivors which could be met by an oncology rehabilitation approach modeled after a

successful CR program. Components of CR programs that provide the framework needed

for oncology rehabilitation interventions are presented. We also describe a successful

oncology rehabilitation program that uses a CR approach to chronic disease management.

REVIEW OF RELEVANT LITERATURE

Impact of Cancer and Cancer Treatment: Declines in Fitness, Strength, and Physical

Function

The interplay of cancer and various cancer treatments results in physiologic decline and

persistent side effects most of which can be improved with exercise and rehabilitation (Table

1).

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Cardiorespiratory fitness is impaired in cancer survivors.16 In a recent meta-analysis by our

group, we found fitness to be 25% lower among breast cancer patients in the post-adjuvant

setting compared to healthy, sedentary women.17 Specifically, breast cancer patients 50

years of age had a similar fitness to sedentary, 60 year old women without a history of breast

cancer. The decline in fitness appears sustained in breast cancer patients even 7 years after

treatment compared to age-matched controls.18

Muscular strength is a key component of overall fitness. There is limited research evaluating

the natural history of skeletal muscle strength among cancer survivors and the data we do

have is gleaned from studies completed for other reasons. In a small prospective study of

patients receiving an autologous transplant, upper extremity strength decreased by 24% and

lower extremity strength decreased by 9% in 25 days from pre to post transplant.19 Recently

reductions in the intrinsic function of skeletal muscle myofilaments has been identified in

cancer patients and was associated with decreases in whole muscle strength and walking

performance.20

Strength and fitness decline could play an important role in limiting performance of

activities of daily living and development of disability. Among individuals participating in

the National Health Interview Survey almost 60% of those with a history of cancer report at

least one functional limitation compared to 27% of the general population.21 Functional

limitations identified include difficulty walking one-quarter of a mile, walking up stairs, and

lifting or carrying. Cancer-related functional impairment is a particular concern for the 65%

of cancer survivors age 65 or older that depend on function to maintain independence.

Impact of Cancer and Cancer Treatment: Persistent Side Effects

Surgery and radiation are common local treatment modalities that can impair mobility.

Shoulder range of motion is limited in up to 45% of patients receiving sentinel lymph node

evaluation and 86% of those receiving axillary dissections.22 Importantly, this dysfunction

translated into limitations in activities such as household chores (44.2%) and lifting a gallon

of milk (34.9%). Lymphedema can be acquired through disruption of lymphatic drainage

resulting from cancer related surgery or radiation. Therapies to treat breast cancer are

associated with a 21.4% incidence of lymphedema23 and those with lymphedema experience

strength and upper extremity impairment.24 Lymphedema also occurs with treatment of

melanoma, gynecologic malignancies, genitourinary, and sarcoma ranging in incidence from

10–30%.25

The chemotherapeutic and targeted therapies used to treat cancer are associated with

collateral damage that impacts the quality of life for many cancer survivors. Fatigue is the

most commonly identified persistent effects of cancer therapy and is present in up to 80% of

cancer survivors.26 Cancer related fatigue is multifactorial and contributors include

decreased activity, deconditioning, depression and sleep disturbance.27,28 Peripheral

neuropathy results from several chemotherapeutic agents and is reported in up to a quarter of

breast cancer survivors receiving paclitaxel29 and is persistent in nearly half of colorectal

cancer patients receiving oxaliplatin.30 The most common anti-estrogen therapy for postmenopausal breast cancer survivors is aromatase inhibitors which are associated with joint

pain and stiffness in over 40% of individuals.31

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Depending on diagnosis and interventions, either weight gain or loss occurs with cancer

therapy. Weight gain is more common for individuals receiving adjuvant therapy for breast

and colon cancer.32,33 Results from the Nurses’ Health Study revealed that a weight gain of

5–10 pounds after breast cancer diagnosis was associated with 50% higher rates of breast

cancer recurrence and death.34 Conversely, individuals with other malignancies such as

lung, head/neck, pancreatic and upper gastrointestinal, frequently lose weight. This weight

loss results in a reduction in skeletal muscle, is often not reversed by nutrition alone, and is

accompanied by declines in strength.35

Up to 35% of cancer survivors experience significant psychological distress,36 twice the rate

of the general population.37 Even though anxiety and depression decline as individuals

move beyond diagnosis, a significant percentage of breast cancer survivors experience

severe anxiety and depression at 18 months.38 Psychological factors appear to be associated

with physical inactivity among cancer survivors.39

Benefits of Exercise and Rehabilitation for Cancer Survivors

Exercise and rehabilitative interventions have proven beneficial for ameliorating

impairments experienced by cancer survivors (Table 1). Aerobic interventions increase

cardiopulmonary fitness in cancer survivors,40 with increases ranging from 10–15%.16

Aerobic exercise benefits are found for survivors of several different cancers, including

lung, breast, prostate, lymphoma, and hematologic malignancies.41,42 Muscle strength

improves with resistance training interventions for cancer survivors with a variety of

malignancies.43 Increases in strength are also associated with improved physical function,

including gait speed and ability to rise from a chair.44

Exercise and rehabilitative interventions result in improvements in shoulder range of motion

impairment in women treated for breast cancer.45 Resistance training does not worsen

lymphedema and, in fact, appears to decrease incidence of exacerbations and reduce

symptoms.46 A recent review of 56 studies with over 4000 participants identified benefits of

exercise interventions for fatigue management delivered during and after cancer therapy.47

Improvements have been reported in arthralgia pain associated with aromatase inhibitor use

in post-menopausal women receiving an aerobic and resistance training intervention.48

Resistance training also results in decreases in body fat percentage and increases in lean

body mass among cancer survivors.49 Exercise for cancer survivors results in decreased

depression and improved quality of life.50

While a randomized controlled trial is lacking, observational studies identify improved

overall survival among cancer survivors who are more physically active. For breast cancer

survivors, physical activity equivalent to 3 hours of moderate intensity activity is associated

with a 34% reduction in breast cancer-specific mortality and a 41% reduction in all-case

mortality.51 Two large observational studies have demonstrated that 6 hours per week of

moderate intensity physical activity after a colon cancer diagnosis is associated with a

reduction in colon cancer death and death from all causes compared to men or women who

were physically inactive.9,10 Survival benefits with physical activity have also been

identified for prostate cancer52 and glioblastoma.53

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Exercise Recommendations and Challenges for Cancer Survivors

The benefits cancer survivors derive from exercise and the number of deficits amenable to

rehabilitation builds a strong case for establishing oncology rehabilitation programs. The

American Cancer Society and the American College of Sports Medicine (ACSM) have

recommended at least 150 minutes of moderate intensity aerobic physical activity weekly

for cancer patients.54,55 However, survivors appear to decrease their activity after a cancer

diagnosis, even in cases where no clear physical impairments are present. Direct

measurement of physical activity using accelerometers in the NHANES 2003–2006 cohort

indicates that 95.5% of cancer survivors do not meet physical activity recommendations.56

This is a particular concern among those diagnosed with early stage cancers who are likely

cured of their cancer, but are at increased risk for other chronic disease, such as diabetes and

coronary heart disease.

Several barriers exist to improving exercise participation and rehabilitation. Cancer

survivors note lack of facilities (25.5%), weakness (21.5%), and fear of falling (19.5%) as

common barriers to exercise.57 Fear of doing harm as a result of exercise is also a concern.58

Cancer survivors may not exercise on their own. Adherence for a supervised intervention

among lung cancer survivors was 73% compared to only 8.7% for those receiving a homebased intervention.41 Supervised exercise may be needed to support cancer survivor’s

transition to regular exercise. Referral patterns for rehabilitation are not established. Even

among individuals with metastatic cancer, only 30% of those eligible for rehabilitative

interventions obtain these services.59

DISCUSSION AND PROGRAM EXAMPLE

Cardiac Rehabilitation as a Model for Oncologic Rehabilitation

An effective oncology rehabilitation program would improve fitness and address physical

and psychological deficits. CR provides an ideal model for bringing oncology rehabilitation

to cancer survivors at academic and community medical centers across the country. The CR

program staff is trained to identify physical impairments and improve fitness. They are

experienced dealing with a wide range of co-morbid medical conditions. CR programs have

the necessary facilities, systems for referrals and integration into the medical system. Needs

of cancer survivors vary across the trajectory of oncologic care. The phases within in CR

can be used to address diverse needs (Table 2). Phase 1oncology rehabilitation focuses on

correcting severe deficits and deconditioning during oncologic treatment. Phase 2 oncology

rehabilitation addresses ongoing deficits and focuses on improving fitness immediately post

therapy. Cancer patients completing Phase 2 or those well beyond initial cancer treatment

and who do not have significant deficits would enter Phase 3.

Multifactorial CR consists of exercise training, as well as lifestyle counseling and medical

management interventions.11,60 The aerobic exercise component generally consists of 3

weekly ECG monitored exercise sessions for 8–12 weeks with frequency, duration, and

intensity progressing over time and a plan for long-term exercise. Resistance training is

typically provided with a goal to increase strength, skeletal muscle endurance, and

consequently functional capacity.61 CR also includes cardiac risk factor reduction including

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recommendations for smoking cessation, hypertension, dyslipidemia, diabetes, and weight

management. Psychosocial management is a concern for cardiac patients with depression,

anxiety, and denial which occurs in more than 20% of patients following a myocardial

infarction.62

A Phase 2 oncologic rehabilitation program would include many of the core components of

CR (Table 3). Aerobic exercise and resistance training remain central interventions for

oncology rehabilitation. Several of the supportive core modules currently provided in CR

have similar value for cancer survivors, including weight management, stress reduction, and

smoking cessation. In order for survivors to fully participate in exercise interventions, the

common persistent effects of cancer therapy such as fatigue, deconditioning and mobility

deficits need to be addressed. The impact of surgical and radiation interventions are unique

to cancer survivors receiving these modalities and may require additional physical therapy.

Occasionally exercise modalities may need to be modified based on deficits.

Lessons in Establishing an Oncology Rehabilitation Program

In 2011, we initiated an oncology rehabilitation program within the University of Vermont’s

CR facility. The focus was on a phase 2 model, however individuals beyond initial diagnosis

were included. Few recommendations exist as to the baseline evaluations that might be

appropriate for cancer survivors starting an exercise program. The ACSM guidelines

recommend evaluation for musculoskeletal morbidities and peripheral neuropathies related

to treatment regardless of time since treatment.55 Prior to starting the oncology rehabilitation

program, survivors are evaluated by a physician or mid-level provider to assess the

appropriateness of participating in an exercise program and to identify persistent side effects

that may need to be addressed. Previous and current therapeutic agents that contribute to

deficits, such as cardiac impairment, fatigue, peripheral neuropathy, and arthralgias, are

reviewed. Table 4 compares and contrasts the baseline evaluations completed in cardiac and

oncology rehabilitation. A 6-minute walk test is completed to assess functional capacity for

participating in aerobic exercise. If significant anxiety or depression is identified,

participants are directed to our Cancer Patient Support Program if they are not already

connected with a therapist.

Because of the frequency with which oncologic therapies result in musculoskeletal deficits,

a physical therapist (PT) evaluates function prior to individuals entering the program. The

PT evaluates for lymphedema, range of motion, and balance deficits. If sufficient deficit

exists or severe deconditioning is identified, one-on-one physical therapy is provided.

Alternatively, if physical limitations are found but participants are able to start the program,

the PT instructs the exercise physiologist on the required modifications. With the assistance

of a cardiologist specializing in onco-cardiology, participants entering oncology

rehabilitation undergo cardiopulmonary exercise tolerance testing (ETT). The utility and

safety of ETT testing was based on previous review of cardiorespiratory fitness testing in the

cancer setting.63

Data regarding fitness, strength, persistent impacts of cancer therapy, and quality of life are

obtained at baseline and again at the end of the intervention. The data are used to evaluate

the success of the intervention and to examine impacts of cancer treatment on fitness,

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strength, and function. Participants sign an University of Vermont Institutional Review

Board approved consent agreeing to have their data included in a research database.

The exercise intervention consists of twice weekly supervised aerobic and resistance training

for 12 weeks with recommendations to perform aerobic activity on 2–3 additional days each

week. The ACSM recommendations for exercise prescription for cancer survivors are

followed.55 Aerobic exercise training does not require ECG monitoring and exercise

physiologists monitor the exercise sessions. The aerobic exercise intensity is 70–85% of

peak heart rate as determined at the entry ETT. If an ETT is not completed, a rating of

perceived exertion between 12 and 14 is used. Participants perform aerobic activity,

generally brisk walking, for 20 minutes 3–4 times per week progressing to 50 minutes 4 or 5

times per week. The resistance training includes upper extremity and lower extremity

exercise. Initial weight is set at 60–70% of one repetition maximum (1-RM). If a 1-RM is

not available for a particular muscle group initial, the weight is set at a level participants can

move using correct form for at least 8 repetitions. If a participant has lymphedema, they are

instructed to exercise with their compression garment. Balance exercises are included

because a significant number of cancer survivors have balance problems as determined by

single leg stance. Cancer survivors enter the program in groups of 4–6. The first 3 sessions

are conducted by exercise physiologists and they introduce the exercises and equipment to

participants. Thereafter, individuals exercise in a less supervised fashion, with exercise

physiologists available to help participants progress their aerobic and resistance training.

During the intervention, core education sessions focusing on nutrition and stress

management are provided. Additional lectures on topics related to cancer side effects are

available. If individuals are identified to have a particular need or interest in weight control

or stress management, longer programs on each topic are available and can be completed

either during or after the intervention. Each participant has a formal meeting with a staff

member to discuss their plans for continuing to exercise. They can continue to attend

oncology rehabilitation for a small fee. Recently we began sending a 3 month postintervention survey to participants to assess their activity after completing the intervention.

Oncology Rehabilitation Program Results

Between January 2012 and December 2013, 280 cancer survivors were evaluated (Table 5).

The majority were women with a diagnosis of breast cancer. Participants were

approximately 2.5 years beyond diagnosis (range 2 months – 22 years). Twelve percent of

those entering the program require additional physical therapy prior to starting the program.

Of those who were evaluated, 221 (79%) started the program and 164 (74%) of these

completed the program. Over 90% attended more than 15 exercise sessions. Of the

participants completing the program, 6 (2%) died as a result of their malignancy.

Physiologic and Quality of Life Improvements

Table 6 describes changes resulting from the intervention for participants in oncology

rehabilitation from January 2012 through December 2013.

Baseline exercise tolerance tests have been performed on 120 participants with an average

peak oxygen uptake (V̇O2) of 23.4 mL·kg−1 · min−1. Over 70% of participants completing

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baseline ETTs have a peakV̇O2 in the very poor category, with another 15% having

peakV̇O2 measurements consider to be poor. Post-intervention ETTs are performed only for

individuals who received chemotherapy (n = 18) and, for these individuals, peak V̇O2

increased but not significantly. The distance walked in 6 minutes increased significantly

post-intervention. At baseline, the 1-RM chest press was ≤15th percentile (very poor) for

95% of breast cancer survivors at baseline compared to normal age matched individuals.64

Leg press strength was <20th percentile for 68% of participants. Both chest press and leg

press strength increased significantly as a result of the intervention. Fatigue scores, as

measured by the Fatigue Symptom Inventory,65 declined significantly after the intervention.

Depression as measured by PHQ-966 and anxiety as measured by GAD-767 were also

significantly lower after the program. The participants report that the social aspect of the

intervention as important as the exercise.

APPLICATION TO PRACTICE

Disseminating Oncology Rehabilitation: Leveraging the Experience and Opportunities

Provided by Cardiac Rehabilitation

CR programs and facilities provide an ideal framework for developing and disseminating

oncology rehabilitation programs. Our experience demonstrates that a CR model can be used

to provide exercise based oncology rehabilitation that can improve the physiologic and

quality of life parameters of cancer survivors. Minimal changes are needed to provide

oncology rehabilitation at CR sites. A cardiac rehabilitation staff has the expertise necessary

to deal with multiple comorbidities. Education specific to cancer survivor medical

challenges could be provided in 2–3 hours. Physical therapists often collaborate with CR

and are available to address cancer related deficits as well as any orthopedic issues cancer

survivors might experience. CR has the equipment and expertise to provide exercise

interventions and on-site education and lifestyle management are often available.

CR has a wide “reach”. There are over 2,000 programs in the US in both academic and

community settings. The majority of these locations have an affiliated or nearby cancer

center. Many CR sites are underutilized and have the capacity to expand to include oncology

rehabilitation programs. Using existing space that already has the equipment and staff

necessary for rehabilitation is a cost effective way to provide oncology rehabilitation. Many

CR sites have an infrastructure to collect data on the efficacy of their program and to

conduct outcomes research. Oncology rehabilitation would also benefit from similar

research strategies to identify the challenges cancer survivors experience before and during

exercise and to provide outcomes assessment to support potential third-party insurance

coverage in the future.

Challenges of Disseminating Oncology Rehabilitation

Several challenges remain with disseminating oncology rehabilitation to a wider population

of cancer survivors (Table 7). There is a need to add to the limited research evaluating

exercise-based oncology rehabilitation. Comparative effectiveness and dissemination

research is needed to test whether rehabilitative programs result in improvements in patient,

health care system, and cost outcomes. There is a surprising lack of research evaluating the

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natural history of aerobic and strength decline associated with cancer and its therapy.

Information gained from longitudinal studies on the impact of cancer therapy would provide

valuable information for identifying the times of greatest decline and potential recovery.

Focused recommendations about the mode, intensity, and frequency of exercise for many

specific cancer diagnoses are lacking. Ideally oncology rehabilitation would start early

(Phase 1) but there is limited research on the extent to which cancer survivors are willing or

able to participate during challenging oncologic interventions. It is unclear which cancer

survivors require a medically supervised intervention and who can start exercising on their

own or in a community gym setting. Targeting rehabilitation to cancer survivors who would

benefit most is important for determining the efficacy and cost effectiveness of these

programs. Ideally a risk classification system would be created to determine who is at

greatest need.

The impact of cancer therapy is often under recognized by oncology medical providers and

the value of interventions to alleviate cancer related symptoms is often overlooked. At most

cancer centers, there are minimal options for providing oncology rehabilitation. An

infrastructure is needed to provide a seamless transition to rehabilitation and exercise

opportunities and should be considered a standard part of oncologic care. Staff at

rehabilitation sites may need reeducation about the unique challenges of cancer survivors,

such as lymphedema, ROM deficits, and peripheral neuropathy.

There is a lack of insurance reimbursement for oncology rehabilitation. In our oncology

rehabilitation program, components are reimbursed by insurance, but bundled insurance

reimbursement is not available. As a result, some of the cost, in particular supervision in the

gym and lifestyle education modules, must be supported by philanthropic funds. In our

community, stakeholders and the public have been very supportive and finding funds to

support this new program has not been a barrier. However, this is clearly not a long-term

sustainable solution. The current changes in health care delivery may provide an opportunity

to expand medically supervised rehabilitation programs to new populations such as cancer

survivors.

SUMMARY

Oncology rehabilitation using a CR model is a promising intervention for cancer survivors.

Fitness improves as does physical and psychological function. Implementation of oncologic

rehabilitation on a wider scale awaits the collection of controlled data concerning the value

of oncologic rehabilitation versus usual care in contemporary populations. As the cancer

survivor population grows due to improved oncologic treatment, the importance of longer

term functional outcomes will be accentuated.

Acknowledgments

Funding: Drs. Dittus, Lakoski, and Ades are supported by National Institutes of Health Center of Biomedical

Research Excellence award P20GM103644 from the National Institute of General Medical Sciences and Dr. Toth

from the NIH (AG033547).

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Table 1

Impairments Experienced By Cancer Survivors and Improvements with Exercise/Rehabilitation.

Impairments Improvements with Rehabilitation

1. Reduced physiologic capacity:

a. Reduced cardiorespiratory fitness

b. Muscle weakness/atrophy

c. Impaired function/disability

1. Increased aerobic fitness and strength

2. Persistent impacts of cancer therapy:

a. Range of motion deficits

b. Lymphedema

c. Fatigue

d. Pain

2. Decreased deficits and lymphedema symptoms:

a. Less pain and fatigue

3. Weight management:

a. Weight gain

b. Loss of lean body mass and sarcopenia

3. Weight loss/maintenance with exercise and lifestyle interventions; maintenance of lean

body mass with exercise

4. Psychological issues:

a. Depression

b. Anxiety

4. Improved quality of life; decreased depression and anxiety with exercise

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Table 2

Phases of Cardiac and Oncology Rehabilitation.

Phases Cardiac Rehabilitation Oncology Rehabilitation

1 In-hospital interventions including: ROM; self-care progressing to walking and limited stairclimbing Address ROM defects after surgery Deconditioning during oncologic treatment; 1-on-1 physical therapy transitioning to independence and rehabilitative exercise

2 Outpatient structured medically supervised exercise

ECG monitoring

Exercise adjustment regularly by exercise physiologist

Activity under supervision

Risk factor reduction and lifestyle improvement

Structured medically supervised exercise immediately post oncologic therapy

Address persistent side effects and deficits

Supervised exercise progression

Lifestyle improvement

3 Independent group exercise

Monitoring own heart rate

Lifestyle interventions to improve chronic disease management

Independent group exercise

Improve fitness

Lifestyle interventions to improve chronic disease management

Abbreviations: ECG, electrocardiogram; ROM, range of motion.

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Table 3

Core Components of Phase 2 Cardiac and Oncology Rehabilitation Programs.

Cardiac Rehabilitation11 Oncology Rehabilitation

Exercise training Same

Physical activity counseling Same

Nutrition counseling Same

Psychosocial management Same

Weight management Same

Coronary risk factor management:

• Management of hypertension and dyslipidemia

• Diabetes management

• Smoking cessation

Persistent effects after oncology therapy:

• Fatigue/sleep issues

• Surgical/radiation related impairment

• Pain syndromes, arthralgias

• Deconditioning/weakness/balance issues

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Table 4

Baseline Assessments of Participants in Oncology Rehabilitation at the University of Vermont (2011-present).

Cardiac Rehabilitation Oncology Rehabilitation

Medical history Review of CV medical and surgical diagnoses and

procedures

Comorbidities

Depression

Musculoskeletal and neuromuscular disorders

Symptoms of CV disease

Medications

CV risk profile

Review of oncologic history and interventions

Comorbidities

Depression and anxiety

Musculoskeletal and neuromuscular disorders

Medications

Presence of and risk for late/lingering effects of

oncologic therapy

Physical examination Cardiopulmonary systems

Blood pressure

Auscultation of heart and lungs

Inspection of lower extremities for edema

Post-CV procedure wound sites

Orthopedic and neuromuscular status

Cognitive function

Cardiopulmonary systems

Blood pressure

Auscultation of heart and lungs

Inspection of all extremities for lymphedema

Treatment related ROM

Orthopedic and neuromuscular status

Cognitive function

Testing 12-lead ECG

Health-related quality of life

Treadmill test with ECG or 6-minute walk test

6-minute walk test

Health-related quality of life

Treadmill test offered

Abbreviations: CV, cardiovascular; ECG, electrocardiogram; ROM, range of motion.

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Table 5

Baseline Characteristics of Participants in the University of Vermont Oncology Rehabilitation, January 2012

through December 2013.

Total Patients Evaluated (n = 280)

Gender

Male 40 (14%)

Female 240 (86%)

Agea, y 55.8 ± 12.1 years

Type of malignancy

Breast 190 (68%)

Colo/Rectal 6 (2%)

Heme 8 (3%)

Lung 7 (3%)

Prostate 6 (2%)

Other 63 (22%)

Time since diagnosisa, y 2.36 ± 3.7

Oncologic Intervention

Surgery 236 (84.3%)

Chemotherapy 190 (67.9%)

Radiation 204 (72.9%)

aMean ± SD

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Table 6

Physiologic and Quality of Life Parameters of Participants in University of Vermont Oncology Rehabilitation, January 2012 through December 2013.

n Baseline Post-Training % Change P

6-minute walk, m 142 534.2 ± 171 582.7 ± 157.2 8.3% .003

V̇O2peak, mL·kg−1 · min−1 18

a 24.6 ± 6.53 25.8 ± 6.25 7.5% .142

1-RM chest press, lbs 142 63.7 ± 41.2 81.3 ± 44.2 21.6% .000

1-RM leg press, lbs 130 115.7 ± 40.7 147.4 ± 39.9 21.5% .000

Fatigue Symptom Inventory 141 15.7 ± 12.2 10.0 ± 11.8 36.3% .000

PHQ-9, depression score 152 5.34 ± 4.0 3.7 ± 3.5 25.1% .000

GAD-7, anxiety score 154 2.87 ± 3.5 2.34 ± 3.2 18.5% .042

Abbreviations: GAD-7, Generalized Anxiety Disorder; PHQ-9, Patient Health Questionnaire; 1-RM, 1 repetition maximum; V̇O2peak, peak oxygen uptake;

aPerformed on a subset of participants.

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Table 7

Future Directions for Implementing Oncology Rehabilitation Programs.

1. Research needs

a. Controlled interventions to determine recommendations for specific malignancies and for specific times in the cancer survivor

trajectory

b. Information on the natural history of physiologic parameters of cancer survivors

c. Dissemination studies for cancer survivors outside controlled trials

2. Increase awareness and identify oncology ‘champions’

3. Allocation of resources

a. Locations for interventions

b. Acceptance from CR facilities

c. Training to improve comfort level of CR staff

d. Referral systems

4. Lobby for third-party reimbursement

Abbreviation: CR, cardiac rehabilitation.

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