Table 5.

Exercise programming considerations for specific cancer survivors

Consideration	Recommendations.
Bone loss / bone metastases:	• Avoid contraindicated movements that place an excessively high load on fragile skeletal sites. These include the following: high-impact loads, hyperflexion or hyperextension of the trunk, flexion or extension of the trunk with added resistance, and dynamic twisting motion  • Specific guidance on how to modify exercise programs based on the site of bony lesions is provided elsewhere(107, 111)  • Preventing falls must also be a goal of therapy, since falls play an important role in fracture etiology (112).  • Be aware of signs and symptoms of bone metastases in survivors, as well as common locations where these occur (i.e., spinal vertebrae, ribs, humerus, femur, pelvis). Bone pain can be an initial sign of skeletal metastases thus, exercise trainers should refer survivors who report pain back to the medical team for clinical evaluation prior to continuing exercise
Lymphedema	• To date, there is insufficient evidence to support or refute this clinical advice to wear a compression garment during exercise to prevent or reduce symptoms of breast cancer-related upper body lymphedema. Therefore, it is recommended that exercise professionals provide this information as part of client education and defer to an individual client’s preference regarding use of a compression sleeve.  • Being overweight or deconditioned have been associated with a higher risk of developing cancer-related lymphedema in observational studies, at this time there is insufficient evidence that weight loss or improving aerobic fitness can lower the risk of developing cancer-related lymphedema(113).  •
Older adults	• Physical problems reported by cancer survivors, such as cognitive difficulty, neuropathy, sarcopenia, muscle weakness, slowing, and fatigue, may be similar to those of older people without cancer, but cancer treatment can accelerate these declines(114–116)  • Exercise professionals will need to combine ACSM guidelines on exercise programming for older adults(117) with the recommendations in this publication.  • Integrate fitness and functional assessments prior to beginning an exercise program to more accurately determine baseline functional abilities.
Ostomy	• Empty ostomy bag before starting exercise  • Weight lifting/resistance exercises should start with low resistance and progress slowly under the guidance of trained exercise professionals. People with an ostomy may be at an increased risk of parastomal hernia. To regulate intra-abdominal pressure, correct lifting technique and good form is required. Avoid use of a Valsalva maneuver(118, 119).  • Modify any core exercises which cause excessive intra-abdominal pressure, namely a feeling of pressure or observed bulging of the abdomen.  • Those with an ileostomy are at increased risk of dehydration. Get medical advice on ways to maintain optimum hydration prior, during and after exercise.  • Those doing contact sports or where there is a risk of a blow to the ostomy may wish to wear an ostomy protector/shield.
Peripheral Neuropathy	• Stability, balance, and gait should be assessed before engaging in exercise; consider balance training as indicated  • Consider alternative aerobic exercise (stationary biking, water exercise) rather than walking if neuropathy affects stability or use treadmill with safety handrails  • Resistance training recommendations:   ○ Monitor discomfort in hands when using hand-held weights   ○ Consider using dumbbells with soft/rubber coating, and/or wear padded gloves   ○ Consider resistance machines over free weights(120)
Stem cell transplantation	• Home-based exercise encouraged  • A full recovery of the immune system recommended before return to gym facilities with the general public  • Start with light intensity, short durations but high frequency and progress slowly  • Exercise volume (intensity and duration) should be adapted on a daily basis based on the individual’s presentation
Symptom Clusters	• Symptoms and side effects of cancer treatment rarely appear in isolation; rather, symptom clusters are the norm (i.e., fatigue, pain, sleep disturbance), especially during cancer treatment and in those with advanced disease(121).  • Exercise professionals must be aware of this complexity and be prepared to refer clients/patients back to the medical team (i.e., rehabilitation or oncology physician, general practitioner, or nurse) for review and management of symptoms when safety concerns develop or when target symptom (e.g., fatigue) is not responding as expected.
Sun Safety	• In addition to melanoma survivors(122), survivors of cancer at other primary sites may be at increased risk for secondary skin cancers(123)  • Exercise professionals should recommend that cancer survivors engage in sun protective practices when exercising outdoors(124).