Table 2.

Framework with alternations for the exercise and dietary intervention

Comorbidities and adverse effects of ovarian cancer and its treatment	Considerations	Actions/strategy
Comorbidities
Disorders of the thyroid gland (ie, hypothyroidism/hyperthyroidism)	Consider the following complications of disorders of thyroid gland:
	Weight loss or weight gain	Refer to a dietitian when weight loss/weight gain occurs
	Bradycardia in hypothyroidism or tachycardia in hyperthyroidism	Explain to patient bradycardia/tachycardia due to hypothyroidism/hyperthyroidism
		Monitor symptoms: in case of persistent coexisting symptoms (dyspnoea, anxiety, fatigue), terminate exercise and refer to a physician
	Low energy/fatigue in hypothyroidism	Explain to patient fatigue due to hypothyroidism
		Refer to a physician when fatigue does not reduce in a few weeks
Disorders of gallbladder, biliary tract and pancreas (ie, cholelithiasis)		Monitor symptoms and in case of persistent pain, terminate exercise and refer to a physician
Malignant neoplasms (excluding basal cell carcinoma)*	Consider comorbidities and adverse effects of malignant neoplasm that might interfere with the intervention
Adverse effects of ovarian cancer
Ascites (60%)	Consider the following complications of ascites:
	Discomfort	Adjust exercise to a comfortable intensity or posture
	Pleural effusion and/or shortness in breath	In case of disproportional dyspnoea, terminate exercise session and refer to a physician
	Diminished nutritional intake	Refer to a dietitian
Adverse effects of chemotherapy and surgery
Abdominal wound		In the postoperative period (4–6 weeks), exercise is allowed, but pressure on the abdomen should be avoided; therefore, the ‘abdominal crunch’ and ‘pullover’ could be replaced with a ‘lateral raise’ and ‘leg extension’
		After 4–6 weeks, isometric exercises could be replaced by eccentric exercises
		Monitor symptoms: in case of pain or discomfort, decrease training intensity or resistance
	Consider the following complications of an abdominal wound:
	Fever >38.5°C due to wound infection	Contraindication for exercise, refer to a physician
Intestinal stoma		See recommendation under ‘abdominal wound’
		Avoid contact sport (eg, football or martial arts)
	Consider the following complications of an intestinal stoma
	High-output stoma (production of >1 L per 24 hours during ≥3 days)	Contraindication for exercise, refer to a physician and/or dietitian
(Risk of) lymphoedema in legs		Monitor leg volume during exercise programme; ask for symptoms of lymphoedema
		Refer to a lymphoedema specialist when lymphoedema is present or when leg volumes increases and symptoms arise (advice on how to progress with exercise)
	Consider the following complications of lymphoedema in legs:
	Numbness/loss of sensation	Be careful with exercises that include walking, running or balance to prevent falls
		Advise patient to wear good-fitting, stable footwear with good grip under surface
Deep vein thrombosis (in leg)		Contraindication for exercise, refer to a physician when the following symptoms occur: pain in the leg, red or discoloured skin or a feeling of warmth
Thrombophlebitis		Avoid pressure or impact on affected area
		Monitor symptoms and in case of pain or discomfort decrease training intensity or resistance
Nervousness/confusion	Consider the following causes of nervousness/confusion
	Severe anxiety or a psychiatric disorder	Give the patient time to discuss feelings or thoughts
		Contraindication for exercise, refer to a physician when a serious psychiatric disorder might be present
Gastrointestinal symptoms (ie, anorexia, dyspepsia, constipation, taste disorder, dry mouth, mouth ulcers, stomatitis)	Consider the following complications of gastrointestinal symptoms:
	Diminished nutritional intake	Refer to a dietitian and/or physician
Melaena		Contraindication for exercise, refer to a a physician

*Patients with a current other malignancy or prior diagnosis (within 5 years) of cancer were excluded from participation in the Physical Activity and Dietary intervention in OVArian cancer study.