Table 2.
Summary of recommendations and levels of evidence
| CPGs | Level of evidence | Strength of recommendation | PA recommendation |
|---|---|---|---|
| ACS 2016 [36] | LoE (IA-c, IIA-c, III, 0, 2a) | LoE (IA-c, IIA-c, III, 0, 2a) | Regular physical activity: (a) should avoid inactivity and return to normal daily activities as soon as possible after diagnosis (LOE = III); (b) should aim for at least 150 min of moderate or 75 min of vigorous aerobic exercise per week (LOE = I, IA); (c) should include strength training exercises at least 2 d/wk (LOE = IA) |
| ASCO 2016 [42] | Grade (high, moderate, low, very low) | Strength of recommendation (strong, moderate, weak) | Physical medicine and rehabilitation: Clinicians may prescribe directly or refer patients to other professionals to provide the interventions (physical therapy, occupational therapy, recreational therapy, individualized exercise program, orthotics, ultrasound, and heat/cold) to mitigate chronic pain or improve pain-related outcomes in cancer survivors. These interventions must take into consideration pre-existing diagnoses and comorbidities (type, evidence-based; benefits outweigh harms; evidence quality, intermediate; strength of recommendation, moderate) |
| ASCO 2019 [43] | Grade (high, moderate, low, very low) | Strength of recommendation (strong, moderate, weak) | Clinicians should actively encourage patients to engage in a combination of exercise types, including balance training, flexibility or stretching exercises, endurance exercise, and resistance and/or progressive strengthening exercises, to reduce the risk of fractures caused by falls. Whenever possible, exercise should be tailored according to the needs and abilities of the individual patient. Patients with an impairment hindering their gait or balance should be offered medical rehabilitation (type, evidence-based; benefits outweigh harms; evidence quality, low; strength of recommendation, moderate) |
| ASCO 2018 [44] | Grade (high, moderate, low, very low) | Strength of recommendation (strong, moderate, weak) | IADL deficits or falls: PT and/or OT should prescribe strength and balance training, assistive device evaluation, home exercise program, and safety evaluation (type, informal consensus; evidence quality, moderate; strength of recommendation, moderate) |
| SIO 2017 [32] | USPSTF (I, II-1, II-2, II-3, III) | USPSTF (grades A–D, H, and I) | Anxiety: Yoga is recommended for reducing anxiety (grade B) Depression/mood disturbance: Yoga is recommended for improving mood and depressive symptoms (grade B) Fatigue: Yoga can be considered for improving fatigue post treatment (grade C) Quality of life: Yoga is recommended for improving quality of life (grade B); Qigong can be considered for improving quality of life (grade C) |
| NICE (NG101) [33] | Grade (high, moderate, low, very low) | NA | Arm mobility: Give instructions on functional exercises, which should start the day after surgery, to all breast cancer patients undergoing axillary surgery. This should include relevant written information from a member of the breast or physiotherapy team |
| NCCN Adult Cancer Pain [45] | NA | NCCN (categories 1, 2A, 2B, 3) | Pain likely to be relieved or function improved with physical modalities, including supportive devices; positioning instruction; instruction in therapeutic and conditioning exercise; energy conservation and pacing of activities; massage; heat and/or ice; transcutaneous electrical nerve stimulation (TENS); acupuncture or acupressure; ultrasonic stimulation (category 2A) |
| NCCN Antiemesis [46] | NA | NCCN (categories 1, 2A, 2B, 3) | Anticipatory nausea and vomiting prevention/treatment: relaxation exercises (guided imagery; progressive muscle relaxation; biofeedback; music therapy); yoga, if approved by physician (category 2A) |
| NCCN Cancer-Related Fatigue [47] | NA | NCCN (categories 1, 2A, 2B, 3) | Interventions for patients on active treatment/post-treatment: yoga (category 1) |
| NCCN Survivorship [38] | NA | NCCN (categories 1, 2A, 2B, 3) |
Physical activity for cancer survivors: Survivors should strive for at least 150 min of weekly activity with an ultimate goal of 300 min or more of moderate-intensity activity or 75 min of vigorous-intensity activity or equivalent combination spread out over the course of the week; two to three sessions per week of strength/resistance training that include major muscle groups; stretch major muscle groups at least 2 days per week on days that other exercises are performed (category 2A) Cancer-associated cognitive dysfunction interventions: Recommend routine physical activity (see physical activity for cancer survivors); consider meditation, yoga, mindfulness-based stress reduction, and cognitive training (category 2A) Fatigue: recommendations to maintain adequate level of physical activity (category 1) (see physical activity for cancer survivors) Lymphedema: compression garments; progressive resistance training under supervision; manual lymphatic drainage; range of motion exercises (category 2A) Pain syndromes: ① for post-radical neck dissection pain (stretching, range of motion, soft tissue massage, myofascial release, trigger point injections, botulinum toxin injections); ② myalgia, arthralgia pain (physical activity (category 1 for AI-induced arthralgia), heat, cold pack, aquatic therapy, massage, acupuncture, yoga); ③ skeletal or vertebral compression pain (bracing, mobility, weight bearing exercise when pain improves, thoracic and lumbar stabilization exercise); ④ myofascial pain syndrome (physical activity, range of motion exercises, strength exercises, soft tissue myofascial release, ultrasonic stimulation, acupuncture); ⑤ pelvic pain syndrome (pelvic floor exercises) (category 2A) Hormone-related symptoms: physical activity/exercise, Integrative therapies including yoga and cognitive behavior therapies (category 2A) Obstructive sleep apnea: physical activity (category 2A) |
| ESPEN 2017 [39] | LoE (high, moderate, low, very low) | Strength of recommendation (strong, weak) |
Maintenance or an increased level of physical activity in cancer patients to support muscle mass, physical function, and metabolic pattern (strong, high) Individualized resistance exercise in addition to aerobic exercise to maintain muscle strength and muscle mass (weak, low) We recommend that cancer survivors engage in regular physical activity (strong, low) |
| APTA 2020 [34] | LoE (I–III) | APTA (A–C, best practice) |
Postoperative exercise and resumption of activity should be coordinated with the interprofessional team, and an individualized exercise program should be gradually increased while monitoring for adverse events (best practice) Progressive resistance training is safe when an individualized program is supervised beginning at least 1 month postsurgery (grade A) Individualized aerobic exercise programs should be provided (grade A) Individualized programs of aerobic and resistance exercise should be provided for those who have BCRL (stages 0–III) (grade A) Yoga may be a safe form of exercise but does not show evidence of effectiveness for lymphedema volume reduction (grade C) |
| AGO 2020 [35] | Oxford (1a-c, 2a-c, 3a-b, 4, 5) | AGO (+ + , + , + / − , − , − −) | Physical exercise (endurance training 3 times a week in combination with workout exercises 2 times a week) on quality of life, cardiorespiratory fitness, physical performance, sleep, pain, depression, lymphedema, and fatigue (LoE 1a/A/ AGO + +) |
| CPA 2021 [37] | BRIDGE-Wiz (I–V) | BRIDGE-Wiz (A–D, P, R) |
Clinicians may offer home-based/unsupervised aerobic exercise to patients with MM to increase cardiorespiratory fitness and physical activity levels during the ambulatory period before autologous high-dose stem cell transplant (HSCT) (evidence quality, III; recommendation strength, C) Clinicians may offer supervised mixed aerobic/strength training exercise in the inpatient or outpatient setting to patients with MM while undergoing chemotherapy/HSCT (evidence quality, III; recommendation strength, C) Clinicians may offer home-based (unsupervised) mixed aerobic/strength training to patients with MM undergoing chemotherapy/HSCT (evidence quality, I; recommendation strength, B) Clinicians may offer supervised and/or unsupervised individualized strength and aerobic or strength training alone in the outpatient and/or home-based setting to multiple myeloma patients when they are medically stable after chemotherapy/HSCT (evidence quality, II; recommendation strength, B) |
| ASCO 2022 [41] | Grade (high, moderate, low, very low) | Strength of recommendation (strong, moderate, weak) | Oncology providers should recommend aerobic and resistance exercise during active treatment with curative intent to mitigate side effects of cancer treatment (type, evidence-based; benefits outweigh harms; evidence quality, moderate to low; strength of recommendation, strong) |
| ACS 2022 [40] | NA | NA | To improve long-term health and increase the likelihood of survival: Engage in regular physical activity, with consideration of type of cancer, patient health, treatment modalities, and symptoms and side effects. To reduce risk of a new cancer: Engage in 150–300 min of moderate–intensity physical activity per week (or 75–150 min of vigorous-intensity physical activity); striving to meet or exceed the upper limit of 300 min is ideal |
ACS, American Cancer Society; ASCO, American Society of Clinical Oncology; SIO, Society for Integrative Oncology; NICE, National institute for Health and Care Excellence; NCCN, National Comprehensive Cancer Network; ESPEN, European Society for Clinical Nutrition and Metabolism; APTA, American Physical Therapy Association; AGO, German Gynecological Oncology Group; CPA, Canadian Physiotherapy Association; NA, not applied; USPSTF, United States Preventive Services Taskforce; BRIDGE-Wiz, Building Recommendations in a Developer’s Guideline Editor