ACSM Guide To Exercise and Cancer Survivorship Final

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ACSM's
Guide to Exercise and
Cancer Survivorship
f 广） American College of Sports Medicine

Melinda L. Irwin
Editor
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ACSMrs Guide
to Exercise
and Cancer
Survivorship
ACSM's Guide
to Exercise
and Cancer
Survivorship
American College of Sports Medicine
Melinda L. Irwin, PhD, MPH

Yale School ofMedicine
J* Editor
Libnin of Coti|*rc» CaLdugitte-in-Publkalion Data
ACSMS guide lo exerviê and cancer Mirv iv(*rship / Amencan College of Spun、Medicine . Melinda L. Icwin. editor.
p. ；cm. 서
Amenom CoUefe of Spurts Medicine's guide to exercise and cancer survivonhip
Guide Id exercise and cancer survivonhip
Includes bibliographical refefencc* and index.
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I. Irwin. Melinda L. II. Amerkan College of Spurt% Medkine III. Title: American College of Sporu Medicine'* guide lo exercise
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Contents
Contributors ix • ACSM Reviewers xi • Preface xiii • Acknowledgments xvii
CHAPTER 1 Diagnosis and Treatment of Cancer............................... 1

Larissa A. Korde, MD, MPH
Cancer Incidence and Survival.............................................. . .m ..f.......................... 2

Cancer Biology........................................................... 겨.............. 厂
.............................. 2
Cancer Staging................................................. • 그 … 은
............................................. 3
Cancer Screening and Diagnosis........................... ............................................................ 5
Cancer Recurrence Warning Signs.................... ^3.... r............................................ 12
Summary................................................... .................................................................... 12
References...................................... 스. .겨L....................................................... 12
CHAPTER 2 Side Effects and Persistent EflFects of Cancer Surgery

and Treatment . . . . ............................................... 15
Tara Sanft, MD, and Melinda L Irwin, PhD, MPH
Side Effects of Cancer SurQery and T『的tment...................................... ............................ 16

Recurrence. New Primaries, Ml Second Cancers........................... （、於........................ 24
Summary ............ 록...................................................
References.......... .J............................................................... 난，卜........................................25
CHAPTER 3 Lifestyle Factors Associated With Cancer Incidence,

Recurrencer and Survival . . . ............................... 29
Heather K. Neilson, MSc# and Christine M. Frtedenreich, PhD
Effect of Body Weight. ........................................... 30

ytffect of Exercise......................................... 33
Effect of Diet............................ 1년々〔.................................................................................. 37
Summary........................................... 40
References..................... 公^》:................................................................................................. 41
CHAPTER 4 Benefits of Physical Activity After a Cancer

Diagnosis.............................................................................. 49
- Kristin L. Campbell, BSc PT, PhD
Physiologicai Effects of Exercise Training........................................................................... 50

Psychotogicai Benefits of Exercise Training........................................................................ 61
Contents
Cancer-Specific Exercise Issues by Body System............................................................... 63

Effects of Cancer Medications or Treatments on Designing an Exercise Program............... 66
Summary..................................................................................... .................................. 68
References................................................................................ 시. X...................... 68
CHAPTER 5 Cardiorespiratory Fitness Testing in Clients

Diagnosed With Cancer................3.................................................73
Lee W. Jones, PhD, and Claudio Battaglini, PhD
Administration of Cardiorespiratory Fitness .................................................. 74

Exercise Testing Safety.............................. 할............................................................................. 82
Summary ................................. . X............................................................................... 85
References................................. 록......... rT.................................................................... 85
CHAPTER 6 Exercise Prescription and Programming Adaptations:

Based on Surgery,Treatment,and Side Effects . .87
Kathryn Schmitz, Ph［乂 MPH
Health Promotion and Risk of Disease Reduction..................... ....................................... 88

Exercise Prescription Alterations to Address Individual Needs. .................................. 90
Benefits and Risks of Exercise and Exercise Training,. .서. ................................................. 96
Exercise Prescription Individualization................. ............................................................ 96
Acute and Chronic Adverse Effects of Treatment .. 乂，............................................... 103
Setting Goals............................................ L ...................................................... 105
Sample Exercise Prescriptions......................................................................................... 108
뉴 References................................................ 111
CHAPTER 7 Nutrition and Weight Management............................... 113

Stephanie Martch, MS, RD, LD, and Wendy Demark-Wahnefried, PhD, RD
Diet in Cancer Prevention, Control, and Overall Health....................................................... 114

Weight Status and Body Composition............................................................................. 116
Weight and Height Assessment....................................................................................... 121
Energy Consumption and Cancer..................................................................................... 125
Diet Composition and Nutrition Status............................................................................. 126
Complementary Alternative Medicine and Functional Foods.............................................. 132
Dietary Supplements...................................................................................................... 133
Summary....................................................................................................................... 135
References..................................................................................................................... 135
CHAPTER 8 Health Behavior Change Counseling.............................. 141

Karen Basen*Engquistr PhD, MPH，Heidi Perkins, PhD, and Daniel C. Hughes, PhD
Effect of Cancer on Readiness to Exercise........................................................................ 142

Theory-Based Methods and Exercise............................................................................... 144
Contents vii
Translating Theory Into Practice................................................. .................................... 147

Summary ............................................................................. 교.. M............................ 150
References....................................................................... JW..................................... 150
CHAPTER 9 Safety, Injury Prevention,

and Emergency Procedures........................................... 153
• Anna L. Schwartz, PhD, FNR FAAN
Cancer*Spedfic Safety Considerations ▲. 치. .t......................................................................154
Emergency Procedures............... ................................................................................... 157
Documentation......................... A............ .................................................................. 158
•••••••••••• • • ■ ■ • • •■•••■•■■■■••■•••■■•■•■•■•••■•••■■•■•■•■•I 58
References.............. ...................................................................................................... 160
CHAPTER 10 Program Administration...............................................161

Carole M. Schneider, PhD
Designing a Cancer Rehabilitation Program......................... ，，뇨....................................... 162
Cancer Rehabilitation Programs and Settings........................ 165
Program Dpscription and Operations.......................... j‘........................................... 166
Policies and Procedures.................................................... 170
Legal Issues and Documentation................................ 170
Reimbursement Concerns................................... 174
Community-Based Support.......................... 174
SlIfVNDS^f •，•，，，•••••••••••，■，•••••，•••，■•■，，•••••■•••■•••••，••••빠75
References........................... ▲'유. ........................................................................................... 176
Appendix 177 Index 181 About the Editor 187 About the ACSM 189
Contributors
Karen Basen-Engquist# PhD, MPH Ljris&a A. Korde, MD, MPH
Professor Fred Hutchinson Cancer Research Center
Department of Behavioral Science, Cancer Seattle, Washington
Prrvtyntion，and Population Sciences
The University of Texas MD Anderson Cancer Stephanie Martch, MS, RD, LD
Center Project Director ",
The University of Trxx MD Anderson Cancer
Claudio Battaglint PhD Center
Assistant Professor
Dq>artment of Exercise and Sport Science Heather K. Neilson, MSc
University of North Carolina at Chapel Hill Epidemiology Research Associate
Alberta Health Services―Cancer Care
Kristin L. Campbell BSc PT, PhD
Assistant Professor Heidi Perkins, PhD
Department of Physical Therapy
Faculty of Medicine irtment of Kinesiology
University of British Columbia University
Wendy Demark*Wahnefried, PhD, RD Tara Sanft MD

Professor and Webb Endowed Chair ot Nutrition Assistant
Sciences Yale School of Mi
Associate Director Director of the Adult Survivorship Clinic
University of Alabama at Birmingham Yale Cancer Center
Comprehensive Cancer Center
Kathryn SchmiU PhD, MPH
Christine M. Friedenreich, PhD AsMKiatF fYofessor
Senior Research Scientist / Epidemiologist Department of Biostatistics and Epidemiology
AHFMR Health Senior Scholar University of Pennsylvania School of Medicine
Alberti Health Services—Cancer Care
Carole M. Schneider, PhD
Daniel C. Hughes, PhD Director, Rocky Mountain Cancer Rehabilitation
Institute for Health Promotion Research Institute
University of Texas Health Science Cent Professor, School of Sport and Exercise Science
San Antonio University of Northern Colorado
Lee W. Jones, PhD Anna L. Schwartz, PhD, FNP, FAAN

Associate Professor Affiliate Professor
Research Director, Duke Center for Cancer School of Nursing
Survivorship University of Washington
Department of Radiation Oncology
Duke University Medical Center
IX
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ACSM Reviewers
James R. ChurilU PhD, MPH, MS, RCEP SJk.E. Headley, PhD, FACSM，RCEP, CSCS
ACSM Program Director Certified Professor
Assistant Professor Exercise Science and Sport Studies
Clinical and Applied Movement Sciences Springfield CoilqQe
Brooks College of Health
University of North Florida Sherry Barkley, PhD,CES，RCEP
Assistant Professor and Chair
Ildiko Nyikos, MA，ACSM RCEP HPER Department
Research Specialist Augustana College
Lakeshore Foundation
Nikki Carosonc, MS，CPT
William F. Simpson，PhD, C王S, FACSM Long Island University
Associate Professor School of Health Sciences
University of Wisconsin-Superior Adjunct Professor of Exercise Physiology
Department of Health and Human Performance General Manager
Associate Professor Plus One Health Management k <
Director, Exercise Physiology Laboratory
Paul Sorace, MS, RCEP
Mark A. Patterson, MEd, RCEP Clinical Exercise Physiologist
Registered Clinical Exercise Physiologist Hackensack University Medical Center
Department of Cardiovascular Services
and Department of Vascular Therapy Peter Ronai, MS, FACSM，RCEP, CES, CSCS-D
Kaiser Permanent^一Colomdo Region Clinical Assistant Professor
Exercise Science
Madeline Patemostro Bayles, PhD, FACSM Sacred Heart University
Professor
Health and Physical Education
Indiana University of PA
xi
Preface
In the last couple of decades, we have made con ognized scientists studying the effects of exercise
siderable progress in diagnosing certain cancers on cancer survivorship and oncologists treating
earlier and treating many cancers more effectively. cancer patients.
During this time physical activity has emerged The ACS and ACSM physical activity guidelines
as an important modifiable health behavior that are very important for motiv ating more clinicians
also plays a key role in both the prevention and to recommend exercise and refer their patients to
treatment of certain cancers. Although we have qualified fitness professionals, which in turn may
known since the 1980s that being physically active encourage health insurance companies to cover
is associated with reductions in the risk of being exercise programs for cancer survivors, as they do
diagnosed with many cancers? it was not until 2005 cardiac rvhabilitdtiun programs. Equally important,
that the first paper was published examining the however, is ensuring that fitness professionals are
importance on survival of being physically active educated in how to work with cancer survivors.
after a diagnosis of cancer.2 Since 2005, many more They must understand what a cancer diagnosis
studies have been published that consistently show entails, the types of surgeries and treatments com
a benefit of being physically active and a reduced monly prescribed, how these treatments affect
risk of developing a recurrence or dying of cancer the body, and how exercise may facilitate a faster
or other related causes.1^ recovery from surgery and treatment and ultimately
A common question people ask after a diag improve survival rates.
nosis of cancer is, "What can I do to improve my To meet this need for fitness professional train-
chances of survival?” Because physical activity has ing, in late 2006 the ACS, under the direction of
been shown to have a multitude of health benefits Colleen Doyle, the ACS Director of Nutrition and
including fewer side effects of chemotherapy and Physical Activity Division* ivached out to the ACSM
radiation and improved quality of life and survival, to discuss the development of a certification exam
and because it is safe and easy to implement/ * for fitness professiaiwls. The purpose of this exam
more clinicians and oncologists than ever before are would be to test fitness professionals* knowledge
recommending that their patients exercise. Patients about the benefit^ of exercise for cancer survivors,
are seeking opportunities to iram how to exercise and their ability to adapt and tailor exercise pro
safely given the side effects of their surgeries and grams for this population.
treatments or their pvediagnosis lifestyles. Although some courses on how to develop
As a result of the giowing research showing that exerd«c programs fo『 cancer survivors were being
exercise ameliorates the side effects of treatment ottered around the country, none were based on
and improves survival rates, and the increase in exidence-based medicine, and none were developed
inquiries about physical activity to cancer fcxin- with the input of scientists and oncologtsts. Thus, the
dations across the country, the American Cancer ACS and ACSM invited 10 scientists and oncologists
Society (ACS) and the American College of Sports to develop a specialty certification for fitness profes
Medicine (ACSM) decided to issue physical •Ctiv- sionals working with cancvr survivors. The scientists
ity guideUnes for cancer survivors/" The ACS first and oncologists first met in early 2007 to discuss the
published its physical activity guidelines for cancer qualifications needed for becoming certified and the
survivors in 2006/ the ACSM followed with its envn scope of practice for fitness professionals with this
guidelines in 2010." Both sets of guidelines were certification. The first draft of the certification exam
created in round table discussions that occurred was beta-tested in 2007, and it went live in December
over many days in meetings and telephone and 2008. The certification was tided ACSM / ACS Certi
e-mail conversations among internationally rec fied Cancer Exercise Trainer (CET).
xiv Preface
Fitness professionals can now take this computer- nutrition and weight management; health behavior
based exam at various testing locatkms around the change amnseling; injury prevention; and program
country (visit www.acsm.org for more informa administration. Each chapter was written by an
tion). Although a number of organizations offer expert in the field of treating cancer survivors or
workshops, books, or information on how to modify researching the effects of exercise on cancer sur
exercise programs for cancer survivors, the ACSM vivorship. Each chapter also includes a handful of
CET is the only evidence-based certification exam take-home messages to offer practical applications
that undcwent a rigorous development process of the topics dkcu«scd. The tike-home messages
that included experts in the field—both researchers highlight issues such as safety and how to deal
and clinicians— treating cancer patients. with certain situations. Each chapter also includes
In early 2009, the ACSM, with its educational forms and questionjuires, such as sample letters
partner Fitness Resource Associates, developed a to the client, medical and cancer treatment history
webinar series for those wanting to take the CET forms, and exercise questionnaires, to help fitness
exam as well as for those wanting to learn about pmfessioruls begin an exercise pntgram with a new
exercise and cancer patients to earn CECs or simply client. This book is a resource manual for study
for their own edification. Dr. Kathryn Schmitz, asso ing for the ACSM/ACS Certified Cancer Exercise
ciate professor at the University of Pennsylvania Trainer exam, while also offering comprehensive
and an international leader in the field of exercise information on how to develop and adapt exercise
and cancer survivorship research, developed and programs for cancer survivors.
presents the webinar curriculum. Today, with this textbook, along with the ACSM
Although the webinars have been extremely webinars, the ACS and ACSM physical activity
beneficial for increasing knowledge regarding hoiv guidelines, and the ACSM/ACS Cancer Exercise
to modify exercise programs for cancer survivors, Trainer certification, there are more resources
the ACSM thought it was also important tp offer a than ever before to help one specialize and excel
textixiok to use both to prepare for the 션cam and in de\reloping safe and effective exercise programs
to refer to when working with cancer survivors. for cancer survivon. Research tells us that exercise
ACSMfs Guide to Exercise and Cancer Survivorship after a cancer diagnosis decreases the risk of a recur
includes 10 comprehensive, yet concise chapters rence, improves 촌irvival rates, and decreases the
that present the science behind the benefits of exer side effects of têatment.^
cise to cancer survival, as well as the application of Those who were physically active before a cancer
that science to the development or adaptation of diagnosiMiHen wewtder whether exercising was pro-
exercise programs forthose diagnosed with cancer. tective. Research shows that exercise delays tumor
The intention of each chapter is to train the trainer growth so that a person may be diagnosed later
in dcx eloping and adapting exercise programs for at age 70 rather than 50) or at an earlier disease
cancer survivors. Although this textbook was writ stage (e.g., stage I rather than stage III). Research
ten primarih- for the fitness professional, it is very also shows exercise benefits those who were not
relev ant to any professional 1 working with cancrr physically active before diagnosis. It is never too late
survivors_一physical therapists, occupational thera to start an exercise program. Becoming physically
pists, nurses, oncologists, general practitioners, and active can have clinically meaningful effects such as
nutritionists__as well as to petiple diagruwed with better recovery from surgery, fewer negative side
cancer or caring for cancer survivors. effects of treatment, and increased survival rates.
The chapters focus on all the knowledge and We hope this textbook will increase fitness pro
skills (which are listed at the beginning of each fessionals* knowledge of the importance of exercise
chapter) that are the source for the content of the after a cancer diagnosis, as well as their skills at
CET exam while also offering examples of exercise developing and adapting exercise programs. The
adaptations for cancer survivors. Topics include more certified exercise trainers there are, the more
the incidence and prevalence of the most common exercise opportunities there will be in our commu
cancers; common cancer treatments and side effects; nities for those diagnosed with cancer. Our hope
the benefits of exercise after a diagnosis of cancer; is that this textbook is not just a tool for educating
exercise testing, prescription, and programming; the fitness professional, but is also a means toward
Preface xv
increasing the physical activity levels of, and in with high vegetable-fruit intake regardless of obesity.
turn improving the quality and quantity of years / Clin Oncol. 2007； 25: 2345-2351.
for, people diagnosed with cancer. 6. Stemfeld B, Weltzien E, Quesenberry CP Jr., et al.
Physical activity and risk at recurrence and mortality
References in breast cancer Mir\'iyor»： Findings from the LACE
study. Cancer Epidaitiol Biomarkers Prev. 2009 Jan；
1. Thune 1, Ferberg A. Physical activity and cancer risk： 18(1):87-95.
Dose-response and cancer, all sites and site specific.
Med Sci Sports Exerc. 20이; 33(6). S53O-S55O. 7. Doyle C, Kiuthi IX, Byer* T. Coumeya KS, Demark-
Wahnefrmd W, Grant B, Me Tieman A, Rock CL,
2. Holmes MD, Chen WY, Feskanich D, et aL Physical
Thompson C, Cansler T, Andrews KS. Nutrition,
activity and survival after breast cancer diagnosis.
Phyniail Activity and Cancer Survivorship Advisory
IAMA. 2抑' 293(20) 247M-2-W6.
Cummittve; Amencan Cancer Society. Nutrition and
3. Irwin ML, Smith A, McHeman A, et al. Association physical activity during and after cancer treatment:
between pre- and post-diagnosis physical activity An American Cancer Society guide for informed
an mortality in bre*»t cancer Mirvivors： The Health, choice*. CA Cancer / Clin. 2006; 56(6>: 323-353.
Eatingz Activity, and Liftstyle (HEAL) Study. / Clin
8. Schmitz KH, Coumeya KS, Matthews C, Demark-
Oncol. 2008; 26(24): 3958-39M.
Wahncfried W, Galvdo DA, Pinto BM, Irwin ML,
4. Holick CN, Newcomb PA, Trvntham*Dietz A, et Wolin KX Segal RJ, Lucia A, Schneider CM, von
al. Physical activity and survival after of Gruenigen VE, Schwartz AL, American College of
invasive brvast cancer. Cancer Epidemiol Biomarkers Sports Medicine- American College of Sports Medi
Prrv. 2008; 17(2): 379-386. cine roundtable on exerci»e guidelines for cancer
5. Pierce JE Stefcinick ML, Flatt SW, ai. Greater sui survivors. Med Sci Sports Exerc. 2010； 42(7)： 1409-
vival after breast cancer in phvocally active women 1426.
Acknowledgments
This textbook, although primarily focused on the with Myles Schra^, senior acquisitions editor, to
development and adaptation of exercise programs the final stages of editing with Amanda Ewing,
for cancer survivors, also covers many additional everything went very smootfily. Although I would
topics including cancer prevention, cancer diagno have loved this book to hdve been published one,
sis, surgical and treatment options, side effects of two, or even five yeai* ago because of the growing
surgpry and treatment, nutrition, injury prevention, number of cancer survivors and the urgent desire
program development, and many other cancer of many professionals to educate and counsel them
survivorship topics. I am extremely grateful to all an the benefits of exercise, the research on this topic
the scientists and clinicians who contributed their was still in 幻s infancy. Thanks to the cutting군dge
expertise and knowledge to this book. Thwe promi research that has been conducted in the past five
nent experts volunteered their time so that this book year^ there is no better time than now to publish
would be made available, primarily for the fitness this book.
professional, but also for the cancer survivor want On that note, I am extremely grateful to the U.S.
ing to make healthy lifestyle changes. National Cancer Institute, ACS, Susan G. Komen
Although a growing number of exercise pro for the Cure, the Lance Armstrong Foundation, and
grams for cancer survivors are becoming avaihble other organizations that sponsor and fund research
throughout the United States and abroad, and this studies focused on exercise and cancer survivorship.
is indeed a good thing, many of these proâms are In addition^ ACSM and ACS have sponsored the
not evidence based or led by certified fitness profes development of consensus statements and recom
sionals. Fortunately, the American Cancer Society mendations for physical activity for cancer survi
(ACS) and the American College of Sports Medicine vors. This book is based ewi those ex-idence-based
(ACSM) had the foresight to bring together the clini recommendations.
cians and scientists who are conducting and leading I also want to acknowledge the many fitness
research studies of exercisetnd cancer surv ivorship professionals eager to safely train cancer survivors.
to develop an evidence-based certification exam for These fitness professional are seeking out oppor
fitness professionals. Thus, I want to thank ACS, tunities, such as the ACSM/ACS Cancer Exercise
specifically Colleen Doyle, and ACSM, including Trainer certification exam as well as this textbook,
Mike Niederpruem, Hope Wood, Kerry CTRourke, to increase their knowledge of how to appropriately
Kela Thomas, and Richard Cotton, for moving this develop and adapt exercise programs.
field forwird and being the only organizations to Last, and most important, I dedicate this book
offer such a certification exam. I have never been to the many cancer survivors I have encountered
prouder of being a member and fellow of ACSM over the years at meetings and conferences and in
than 1 am now. my role as a researcher. Thank you for pushing the
, I also want to thank the editors and staff at field forward, for participating in research, and for
Human Kinetics for publishing this textbook. From making sure opportunities exist beyond surgery and
my initial telephone calls and e-mail exchanges treatment that Focus on the whole person.
CHAPTER 1
Diagnosis
and Treatment
of Cancer
Larissa A. Korde, MD, MPH
Content in this chapter covered in the CET exam outline includes the
following:
• General knowledge of the descnptive epidemiology of cancer, including the prevalence,

incidence, and survival statistics for the major cancer types.
• General knowledge of cancer biology (e.g.. tnihation, promotion/progression. and metastases),
particularly tor the tour most common cancers: lung, breast, colon, and prostate.
• Knowledge of currently accepted screening practices for surveiHance of recurrence for
common cancers (e.g., mammography, colonoscopy, prostate specific antigen, pap smears).
• Knowledge of the pathology tests used to diagnose common cancers (e g., biopsy, imaging
lechnok)g«s, and blood tests for tumor markers).
• General knowledge of current cancer treatment strategies, including surgery, systemic
therapies (e.g., chemotherapy) and targeted therapies (e.g.. anti-angiogenesis inhibitors).
• Understand typical durations of cancer therapy for the major cancers (breast, prostate,
melanoma, ovary, lung, colon), and that therapies are continually evolving/changing.
• Knowledge of the most common warning signs of recurrence fcx common cancers, and when
to recommend that clients seek additional medical evaluation.
2 ACSM's Guide to Exercise and Cancer Survivorship www고csm.org
Cancer is an important cause of morbidity and mor

tality in the United States. It is estimated that more Take-Home Message
than 12 million Americans have a current or past
Cancer is a major health prob
diagnosis of cancer. Knowledge of cancer incidence,
lem in the United States and is
risk factors, treatment, and treatment side effects is an important cause of morbidity
important for health care practitioners and fitness
and mortality among American
professionals working with cancer survivors. This
adults. As cancer treatment and screening
chapter provides an overview at basic cancer biology
improve, the number of cancer survivors in
and addresses incidence, screening, and risk factors
creases. A working knowledge of cancer risk
for common malignancies. In addition, this chapter
factors, incidence, and treatment, as well as
briefly reviews cancer treatment and side effects.
the long-term sequelae of cancer, are impor
tant for professionals working with cancer
survivors.
Cancer Incidence
and Survival
In the United States, cancer is currently the lead Cancer Biology
ing cause of death among women 40 to 79 years of
Cancef occurs when cells in the body escape normal
age and men 60 to 79 years of age, and is second to
mechanisms of control, leading to abnormal cell
heart disease as the most common cause of death
division and proliferation. Cancer cells can also
in adults of all ages. Of note is the fact that death
invade surrounding tissues (Le., metastasis) and
from heart disease has steadily decreased over the
eventually can spread to distant sites through the
past three decades, whereas cancer mortality has
blood and lymph systems. Cancer can arise in vir
declined only slightly among people younger than
tually any part of the body, and cancer types are
85 in the past decade. Among those 85 older,
grouped into broad categories. Carcinoma is cancer
cancer mortality has been basically stable from
that begins in the skin or in tissues that line or cover
1975 to 2005. Lung cancer is the most common
cause of cancer death in men, accounting for 29%
internal organs. Sarcoma refers to cancer that begins
in supportive or connective tissue, such as muscle,
of cancer deaths; prostate and colorectal cancer
account for 11% and 9% of cancer deaths in men. bone, fat, and blood vessels. Leukemia begins in
Lung cancer is also Uw most common cause of blood-forming tissuesand results in abnormal bkxxd
cancer mortality in women, accounting for 26% of cells that circulate throughout the body in the blood.
cancer deaths; breast cancer is responsible for about Ufmphoma and mydema are cancers that originate in
15% of cancer mortality and colorectal cancer for cells of the immune system.
approximately 9%.1 Cancer develops and progresses through the
Although lung cancer is the most common cause accumulation of genetic abnormalities, or muta
of cancer mortality in both men and women, it is tions, within cells. Mutations can occur in genes that
not the most commonly diagnosed cancer in either induce increased activity (oncogenes) or can cause
gender. Prostate cancer is the most prevalent inactivations of genes that generally control celluhr
nancy among men. It is estimated that prostate cancer activity (tumor suppressor genes). Through the accu
will account for 28% of all cancer diagnoses in men, mulation of mutations, cancer cells become resistant
whereas lung cancer will be responsible for approxi to the normal cellular signaling processes, leading
mately 15% of cancer diagnoses. In women, breast to uncontrolled growth and resistance to apoptosis
cancer is the most prevalent form of cancer, account (cell death). Tumors develop the ability to form new
ing for approximately 28% of diagnoses, with lung bkxxd vessels (angiogenesis), which alknvs them to
cancer making up about 14% of malignant cases. In be self-sufficient and to spread. Cancers spread by
both men and women, colorectal cancer is estimated two basic mechanisms: invasion (direct penetration
to be responsible for about 10% of cancer diagnoses into neighboring tissues) and metastasis (penetration
in 2011? Estimates of the number of new cancer cases into lymphatic and blood vessels leading to distant
and deaths for 2010 are shown in figure 1.1. spread and eventual seeding in distant sites).
Diagnosis and treatment of Cancer
Prostate 28% Breast
Lung and bronchus 1S% Lung and bronchus

Coion and rectum 9% Colon and rectum
Urinary bladder 7% Utenne corpus
Melanoma of skm 5% TtyraW
Non-Hodgkin lymphoma 4% Non-Hodglun lymphoma
Kidney and renal peMs 4% Melanoma of stun
Oral cavity 3% lOdney and _<_i pelvn
Leukemia 3% Ovary
Pancreas 3% Pancreas
AN other tHM 19% Al otter sites
Lung and bronchus 29% Lung and bronchus
Prosiaie 11% B<«ast
Coion and rectum 오、 Cokm and reclutn
Pancreas ，乂 Pancreas k
Uwr end mtrah«pattc Mt duct 4% Owy
Leukemia 4% NooHodgkm lymphoma
Esophagus 4% Leukemia
Non-Hodglon lymphoma 4% xUBfine corpus
Urinary biacMer 3% Liver and mtrahepatic Me dud

Kidney and mnaJ peMs 3% Beam or other nervous system
Al other mm 23% Alomar sites
Figure 1.1 Estimated numbers of (a) new cancer cases and (b) deaths in the United States in 2010. These
numbers exclude basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Adapted, by permsaon. from J. Ahmedin et at, 2010. "Cancer stBfis&cs. 2010,* CA Cancer Journal for Chnaans.
Most gene mutations that lead to the occurrence process of staging cancer arose from the observa
of cancer are somatic, meaning that they occur tion that survival rates were generally higher for
within individual cells. However, a small number cancers that were localized compared with those
of cancers are associated with inherited cancer that had spread beyond the organ or site of origin.
syndromes, in which particular gene mutations that Staging can be based on clinical information (e.g.,
predispose people to cancer are passed down from the size of the tumor on physical examination or
parent to child. Families that experience multiple imaging) or pathologic information (measurements
cancers or cancers that occur at earlier'than-usual taken by the pathok)gist after surgical removal of
ages (e.g.z younger than 50 for breast cancer) may a tumor).
warrant referral to a cancer genetics professional. For solid tumors, the American Joint Committee
on Cancer (AJCC) generally uses a classification
system that takes into account the size of a tumor
Cancer Staging (T), the degree of lymph node involvement (N),
and the presence or absence of distant metastases
A staging system is a standardized way to describe (M). Depending on the TNM dassiftca仕on, a tumor
the extent to which a cancer has spread. The is assigned a stage groupings from stage 0 to stage
ACSM's Guide to Exercise and Cancer Survivorship www고csm.org
IV. Stage 0 refers to in situ, or noninvasive, cancer. typically involve the bone marrow and peripheral
This is also sometimes referred to as intraepithe* bkxxi. However, in some cases both manifestations
lial neoplasia. Stages I and 11 generally represent of lymphoid malignancies may be present.
disease that is confined to the site of origin and Tumors that arise from plasma cells, which
kicorcgkmal area. Stages III and IV refer to disease are part of the B-ccU bncage, include multiple
that has spread to distant sites (metastatic disease).2 myeloma and plasmacytoma, and are also con
In general, solid tumors that are diagnosed at an sidered to fall into the spectrum of lymphoid neo
early stage (I and 11) are less likely to result in plasms. The current standard used in clinical trials
mortality than advanced-stage disease (DI and IV). is the Revised European-American Classification of
The U.S. Surveillance, Epidemiology and End Lymphoid Neoplasms (REAL) and World Health
Results (SEER) program monitors cancer incidence (Organization (WHO) classifiedtion, which uses
and mortality in the United States and presents clinical, morphologic, immunophenotypic, and
five-year relative survival figures for various types genetic features over 25 categories of lymphoid
of cancer. The five-year relative survival rate com neoplasms.* The REAL/WHO classification system
pares the observed survival amcmg people with a includes all lymphoid neoplasms: Hodgkin’s
givCTi stage of cancer to what is expected for people lymphoma, non-Hodgkin’s lymphoma, lymphoid
without cancer. This database does not currently leukemias, and plasma cell neoplasms. The staging
report using the AJCC classification system (stag
ing), but rather, groups cancers into local, regional,
and distant stage disease. Five-year relative survival
rates for the most common solid tumors in men and ―당 Take-Home Message
women are shown in figure lJ.1 Cancer staging is based gener-
Lymphoid neoplasms arise from cells of the ally on the size of the primary
immune system, including B-cells, T-cdls, plasma tumor, the presence or absence
cells, and NK (natural killcrl-cells. A number of of the involvement of local or
systems are used for classifying lymphoid neo regional lymph nodes, and the presence or
plasms. Traditionally, classification systems have absence of distant metastases. Stage at di
distinguiithrd between lymphomas, which generally agnosis is direetty related to the prognosis
present with an obvious tumor in either lymph and guides the choice of treatment
nodes or an extranodal site, and leukemias, which
Figure 1.2 Five-year relative survival rates for common cancers by stage at diagnosis.
Date Iram GloecMer Ftes e< at 2003?
Diagnosis and treatment of Cancer
TABLE 1.1 Summary of Ann Arbor Classification of Staging of Lymphoma

Stage Disease involvement
1 Involvement of a single Jymph node region
IE Involvement of a single extralymphatic organ or site
II Involvement of two lymph node regions on the same side of the diaphragm (II) or with
involvement of contiguous extralymphatic organ or tissue (HE)
III Involvement of lymph node regions on both sides of the diaphragm (III) and/or limited
contiguous extralymphatic organ or site (HIE)
HIS As III with involvement of the spleen, or spleen + extranodal organ or site (HIES)
IV Diffuse or disseminated involvement of one or more extralymphatic organs, with or without
associated nodal involvement, including disease present in the bone marrow or liver, or
nodular involvement of the lung(s); OR isolated extralymphatic organ involvement in the
absence of adjacent regional lymph node involvement, but in conjunction with disease in
distant sites
》
Al stagM are further Ovtded on *w bam of *w abMnc* (A or pc__nc« (B) of aytaamic mctuOng l，_r. ragM sweat* tndfct un*î_n«d
weight Iom oi greaser Vian 10% at normal body weight.
Addled from Grew* e< ai. 2002?
system used for defining the extent of disease for test itself may pose a risk of complications (e.g.#
Hodgkin、and non-Hodgkin's Ivmphoma is based perforation during a colonoscopy). In addition,
on the Ann Arbor classifiedtioi\ and is summarized screening tests can result in either false positive
in table 1.1. results, leading to an additional workup for an
abnormality that does not represent true disease, or
夕신
false negative results, leading to false reassurance
Cancer Screening in a person who has the disease. An ideal screening
and Diagnosis test has both a knv false negative rate and a knv false
positive rate, usually referred to as specificity and
sensitivity, respectively.
The purpose of cancer servening to detect a cancer
Current ACS serwning guidelines are presented
at an asymptomatic stage. Because stage of disease
in table 1 오 Note that although lung cancer is the
is generally associated with prognosis, the detection
second most commcm malignancy in adults, routine
of cancer at an early stage can lead to a reduction in
screening is not reccMnmended because, to date, no
mortality.*' In addition, cancer screening can reduce
screening examinabons have been shown to lead
morbidity, because treatment for earlier-stage can
to an earlier diagnosis or improvement in survival
cers or prvmalignant disease is often less aggressive
rates. Similarly, although screening for ovarian
than that for more advanced disease? For screening
cancer has been studied extensively, current data
for a particular disease to be effective, two general
do not support a benefit for routine screening.
criteria must be met：
It is important to note that an abnormal screening
1. A test or procedure exists that can detect the result, such as an elevated prostate-spedfic antigen
disease earlier than if it were detected by symp (PSA), the presence of abnormal cytology on a Pap
toms. smear, or an abnormal finding on mammography,
may not necessarily result in a diagnosis of cancer.
2. There must be evidence that earlier treatment
Rather, an abnormality on screening leads to addi
of the disease results in improved survival.
tional workup aimed at diagnosing or ruling out a
In addition to the potential survival benefits of malignancy. This may include additional imaging
a screening test, a number of potential harms must (specific imaging studies that assist in the diagnosis
also be considered. Although most screening exami of particular cancers are discussed later), but the
nations are noninvasive or minimally invasive, the definitive diagnosis of cancer is generally made by
TABLE 1.2 American Cancer Society Screening Recommendations for Average-Risk,
Asymptomatic People
Cancer site Population Screening test Frequency
Breast Women aged Breast self- Providers should discuss BSE with women beginning in their
^20 years examination (BSE) early 20s. emphasizing the importance of reporting any changes
or symptoms. Women who choose to practice BSE should be
instructed in proper technkûe.
Clinical breast For women in their 20s and 30s, CBE as part of a routine
examination (CBE) physical examination at least every three years is recommended.
Asymptomatic women 40 years oc older should continue to have
CBE, preferably on an annual basts.
Women aged Mammography Women should begin annual mammography at 40,
HO years
Colorectal Men and Fecal occult Annually
women aged blood testing
250 years (FOBT) or fecal
immunochemical
test (FIT); OR
stool DNA test; OR Interval uncertain
flexible Every five years
sigmoidoscopy; OR
FOBT or FIT Annual FOBT or FIT and flexible sigmoidoscopy every five years
and flexible
sigmoidoscopy; OR
double contrast Every five years
barium enema: OR
colonoscopy; OR Every 10 years
computed Every five years
tomography
coIonography
Prostate Men aged 조50 Digital rectal Men with at least a 10-year life expectancy should have the
years exam (DRE) and opportunity to make an informed decision with a health care
proetate-specific provider about whether to be screened for prostate cancer, after
antigen test (PSA) receiving information about the benefits, risks, and uncertainties
associated with prostate cancer screening.
Cervix Women aged Pap lest Cervical cancer screening should begin approximately three
즈 18 years years after a woman begins to have sexual intercourse, but
no later than 21 years of age. Screening should initially be
performed with either a conventional Pap test (yearly) or a liquid*
based Pap test (every two years). At or afte『 age 30. women
who have had three normal consecutive Pap tests may be
screened every two to three years with a Pap test, W- an HPV
(human papillomavirus) DNA test. Women who are >70 years of
age who have had three normal consecutive Pap tests and no
abnormal tests in the past 10 years, and those who have had a
hysterectomy, may elect to stop cervical cancer screening.
Endometrium Women at Women stiould be informed about the risks and symptoms of endometrial cancer and
menopause strongly encouraged to report any unexpected bleeding oc spotting to their physician.
Cancer- Men and Periodic health examination should include examnation for cancers of the thyroid,
related women aged testes, ovaries, lymph nodes, oral cavity, and skin. All patients should be counseled on
checkup 조20 years health practices related to sun exposure, tobacco, diet, nutrition, risk factors, sexual
practices, and environmental and occupational exposures.
. The ULS. 규Sennces Task Force lecommends twennial mammographic screening tor women between the ages at 50 and M*
AdapM. by p*rnw««on. from RA Smith at al. 2010. *Canc«r Kiwrang m the Un_d StalM. 2010: A rwww of currant American Cancer Socwty and imum «i
canoer acfMnlng.* CA C^ncf Journal lor OMcM/M 00 (幻 W-119.
Diagnosis and treatment of Cancer 7
direct examination of tissue, usually by way of a have shown that for appropriate candidates and
needle or excisional biopsy. The workup and treat when followed by radiation, lumpectomy has the
ment for the most common cancers are described in same overall survival rates as mastectomy, although
their respective sections (Le., breast cancer, prostate breast-conserving therapy is associated with a
cancer, and so on) that follow. slightly higher risk of local rrcurreiKr.1' *
Surgical management of invasive breast cancer
should also include evaluation of the axillary
lymph nodes. This can take the form of either an
、，, _ Take-Home Message axillary lymph node dissection or a sentinel lymph
To be effective, a cancer screen* node biopsy, in which the lymph node or nodes
ing test must result in diagnosis that directly drain the area of the tumor are identi
at an early stage, which must re fied and removed. If these initial nodes contain
sult in a decrease in the chance cancer cells, the standard of care is to perform an
of dying from the disease. Currently, screen- axillary dissection. However, if the sentinel node
ing is recommended tor breast and cervical is free of disease, the patient can be spared a full
cancer in women, prostate cancer in men. nodal dissection.” This is particularly important
and colorectal cancer in men and women. because a full nodal dissection is associated with
a higher risk of lymphedema than is a sentinel
node procedure." Studies suggest that 3 to 5% of
patients who undergo sentinel lymph node biopsy
Breast Cancer develop lymphedema, versus 16 to 19% of those
The majority of breast cancers are detected either by who undergo axillary lymph node dissection.1113
an abnormal screening mammogram or a lump pal For patients with known lymph node involvement
pated by either the patient or her physician. A small based on biopsy or dinical findings, an axillary dis-
percentage of patients present with local symptoms is the standard of care.
such as breast pain, breast enlargement, nipple For women who choose breast conservation, and
retraction, or nipple discharge/ Abnormal findings for some women who undergo mastectomy (e.g.,
on screening mammography include calcifications* those with positive surgical rrurgu，，or numerous
architectural distortions, and frank masses. Areas involved lymph nodes), radiation is generally rec
of abnormality can be further evaluated with ultra ommended. For women with stage 0 breast cancer
sound, which helps to determine whether • mass is (ductal carcinoma in s/7i^txnS) who undergo
present and whether the lesion is solid ＜，r cystic. If lumpectomy, radiation ,b also generally recom
a malignancy is suspected by imaging or physical mended. Standard whole breast radiation is typi
examination, a biopsy should be performed; this cally given five per week for five to six wveks.
can be done either with radiologic guidance or via The term adjuvant treatment refers to treatment
a surgical excision. Breast magnetic resonance imag that occurs after the surgical removal of a cancer; it
ing (MRI) is also useful in select cases, either for is aimed at preventing recurrence of disease. Adju
screening in women with a very high risk of breast vant treatment may include radiation, as described
cancer, such as those with a genetic predisposition, earlier, or systemic treatments such as hormonal
or to provide additional information regarding the therapy, chemotherapy, and targeted biologic
extent of disease present in the breast. therapy. The necessity of and options for systemic
Local therapy for breast cancer includes surgi treatment are based on a number of characteristics
cal rt*mcn*al of the tumor, evaluation of the dxilbry of the tumor, including size, grade, the presence
lymph nodes, and if indicated, radiation therapy. or absence of lymph node involvement, and the
When a primary tumor is present, surgical options expression of certain receptors that can guide the
include mastectomy (removal of all breast tissue) use of specific therapies.
and breast-conserving treatment with a lumpec- Women with DCIS (stage 0 breast cancer) who
tomy (removal of the tumor with a wide margin of express hormone receptors may benefit from
normal tissue) followed by radiation. For women adjuvant hormonal treatment. Estrogen receptor is
with large tumors or multifocal disease, lumpec expressed in 50 to 60% of DCIS cases.14 In women
tomy may not be an option. Numerous studies treated with lumpectomy and radiation, additional
8 ACSM's Guide to Exercise and Cancer Survivorship www고 csm.org
treatment with tamoxifen for five years reduces intravenously on the first day of each cycle; in other
the risk of local recurrence and contrahtrral breast treatments, differvnt drug，may be administered
cancer?51* on different days of the cycle (e.g.z weekly or every
In patients with invasive breast cancer whose two weeks). After completion of treatment, patients
turnon exprvs® estrogen or progesterone receptors, should initially hjve a physician visit with clinical
or both (about 70 to 75% of breast cancers), stud breast examination every three to six months, and
ies have shown that treatment with hormonally should also continue annual mammography. Cur
directed medications such as tamoxifen or aroma rently, additional imaging ex*aluati<wi for recurrent
tase inhibitors (anastrozole |brand name Arimidex|; or distant disease is not routinely recommended in
letrozole [Femara]; exemestane (Aromasin)) can the absence of specific symptoms.
reduce the risk of recurrence by 40% or greater, and In pativnts with stage IV, or metastatic, dis
may also have an effect on overall survival?7 These ease, the complete eradication of disease is very
medications are pills that are taken once daily, usu unlikely, and thus treatment is aimed at palliation
ally for at least five years. of symptoms and shrinkage of disease burden. In
About 20 to 30% of breast tumors express this setting, multiple modalities of therapy can be
HER2/neu, a protein that is associated with a more considered, including radiation therepy» hormonal
aggressive subtype of breast cancer. Trastuzumab therapy (for estrogen or progesterone recqjtor-
(Herceptin、a monoclonal antibody to HER2 /neu is positive disease), chemotherapy and targeted
commonly used in combination with chemotherapy therapy, and supportive management such as
for treatment of metastatic, HER2-positive breast pain medication and bone-targeted agents such as
cancer.w Recently, trastuzumab has also been shown zoledronic acid (Zometa). Treatment plans should
to reduce recurrence risk and improve survival in be individualized based on the location of disease,
early-stage breast cancer patient、021 In this setting, tumor burden and aggressiveness, and symptoms.
trastuzumab is generally given in combination with
chemotherapy initially, and then continued for one
year. Trastuzumab is administered intravenously,
Pro빠te Cancer
either weekly or every three weeks. The major Prostate cancer primarily affects older men, with
side effect of trastuzumab is an increased risk of a mean age at diagnosis of 68.22 Many men with
cardiotoxicit)*, and thus cardiac function should prostate cancer, particularly those with localized
be monitored by echocardiogram or nuclear scan disease, die of other illnesses before their prostate
periodically. cancer causes significant disability. Consequently,
The need for chemotherapy in early-stagp breast choice of treatment is often driven by the age at
cancer is also based on tumor characteristics. The diagnosis, the presence of intercurrent illness, and
National Comprehensive Cancer Netwcwk (NCCN) possible side effects of therapy.
recommends chemotherapy for women with tumors There is controversy regarding the value of
that are node positive, and for those with node screening for prostate cancer and the optimal treat
negative disease with certain unfavorable features ment for each stage of disease.11 For a man with
(large tumor size, high tumor grade or other high- an abnonnal screening result additional workup
risk histologic features, hormone receptor negativ generally involves a transrecta 1 biopsy of the pros
ity). There are numerous accepted chemotherapy tate gland, which is usually performed under kx:al
regimens for breast cancer; most include two or anesthesia with ultrasound guidance. Additional
three drugs given concurrently or in sequence. information that may aid in determining the prog
Chemotherapy drugs commonly used in the nosis of the tumor and making therapeutic decisions
treatment of early-stag? breast cancer include adria- include the level of PSA elevation, Gleason score (a
mycin, cyclophosphamide, paclitaxel, docetaxel, histologic grading score on a scale of 2 to 10, with
methotrexate, and 5-fluorouracil. Chemotherapy higher scores indicating Mgh-grade tumors with
for breast cancer is generally given in two- to poorer prognoses》, patient age and comorbid condi
femr-week cycles for four to six cycles, for a total tions, and clinical stage.24
duration of 12 to 24 weeks of treatment. For many Localized prostate cancer can be treated with
standard breast cancer regimens, treatment is given radical prostatectomy or radiation. In selected cases
Diagnosis and treatment of Cancer 9
with favorable prognostic factors, watchful waiting (Nilandron^ taken orally on a daily basis). These
with treatment only at evidence of tumor progres treatments lower tfstostemne levels, leading to a
sion is also an option.25 Surgical management is desired effect on tumoc recurrence and progression,
usually reserved for patients in good health with but have side effect^ including loss of libido, osteo-
tumors confined to the prostate gland (stage 1 or porottis, and impotence.u For this reason, decisions
II).2* Full surgical staging in patients undergoing for treatment should be individualized. Metastatic
radical prostatectomy includes an evaluation of the prostate cancer is generally treated initially with
extent of disease (whether the tumor is confined androgen deprivation, but it eventually beaimes
to the capsule of the prostate gland) and resection resistant to endocrine maneuvers, at which time
margins, and an evaluation of the pelvic lymph chemotherapy may be initiated.
nodes in higher-risk patients.27 If intraoperative
evaluation reveals pelvic nodal metastases, radical
prostatectomy is not usually performed, because
Lung Cancer
risk of recurrence is much greater with extrapros- Lung cancer is the leading cause o( cancer mortal-
tatic disease. ity in the United States in both men and women?
Patients with disease confined to the prostate and Approximately 90°<> of all lung canceTs are related to
surrounding tissue (stages I through liy are candi smoking, with a strong dose-response relationship.
dates for definitive external beam radiation therapy. Risk decreases with smoking cessation, but former
Long-term results of radiation therapy depend on smokers are still at higher risk of lung cancer than
the initial stage of disease; more than 75°o of patients those who have neverjimoked.u People exposed
with T1 disease (incidentally discovered or screen to secondhand smoke are also at increased risk of
detected) are alive withotft recurrence of prostate developing lung cancer compared with nonsmok
cancer at 10 years, whereas those with T4 disease ers without exposure to cigarette smoke.M To date,
(invading into adjacent organs or pelvic wall) have screening of asymptomatic people with an elevated
less than 25% recurrence-free survival at 10 years.* risk of lung cancer because of smoking or other
Interstitial brachytherapy (permanently placed exposures is not recommended, because this strat
radioactive iodine implants in the prostate gland) egy has not been shown to decrease mortality?1
is used at certain centers for patients with favorable Presenting symptoms of lung cancer relate to
tumor characteristics, such as a low Gleason score the location and extent of the tumor. Symptoms
and T1 or T2 tumors, and may be associated with a related to localized obstruction of major airways
lower risk of impotence and other radiation-rvlatrd and the infiltration of lung tissue or surrounding
side effects.1* For more advanced tumors, both blood vessels include cough, shortness of breath,
brachytherapy and external beam radiation may and hemoptysis (coughing up blood》. Tumors that
be used. After prcistatectomy or radiation, patients invade locally into adjacent structures can cause
should be followed with PSA testing and DRE every chest pain, pleural effusion (accumulation of fluid
three to six months; abnormal test results should in the space around the lun呂s》, or shoulder and arm
prompt a further workup with imaging. pain in the case of tumors in the lung apices. Meta
The growth of prostate cancers can be driven by static disease can present with symptoms of distant
androgens, primarily testosterone. Treatments that organ involvement, such as bone pain，neurologic
reduce androgen levels in the body, referred to as symptoms, or mental status changes.15
androgen deprivation therapy, are commonly used In those with new or progressive symptoms,
in the treatment of locally advanced and metastatic an imaging workup, initially with a chest X-ray or
prostate cancer, although the timing of the initia computed tomography (CT) scan of the chest, is
tion of therapy has been the issue of some debate.® recommended. The next step is to obtain a tissue
These include orchiectomy (surgical removal of diagnosis. This can often be done via bronchoscopy
the testes), LHRH agonists (medications such as (a minimally invasive technique for visualizing the
leuprolide (Lupron] or goserelin |Zoladex| usually inside of the airways》for central lesions, but may
given by subcutaneous injection, either monthly or require a CT-guided needle biopsy or surj^ry in
every three months), and antiandrogens (flutamide patients with peripheral lesions or pleural disease.
[Eulexin), bicalutamide (Casodex|# and nilutamide Additional imaging, such as a CT scan, a positron
ACSMrs Guide to Exercise and Cancer Survivorship www.acstn.org
emission tomography (PET apices) scan, or a brain about resectability should be made by a multidisci
MR1 may be required to evaluate for distant disease. plinary tram of thoracic specialists. In some cases,
In addition, in patients who appear to be candidates preoperative chemotherapy, with or without con
for surgical resection, a pulmonary function evalua current radiation, can render tumors operable when
tion should be performed to determine whether they they initially presented as inoperable.
are at risk of pulmonanr compromise or postopera In general, metastatic disease is not considered
tive complications.* operable. Local treatment options for such patients
For treatment and prognosis, lung cancer is include localized radiatioa to decrease tumor
divided into two histologic categories: small burden, and, in some cases, surgical resection of
cell lung cancer (SCLC) and non-small cell lung solitary metastases. Systemic chemotherapy with
cancer (NSCLC). The majority of patients with single agent or doublets should be considered for
SCLC present with advanced-stage disease, and patients with a good perfonnance status. Chemo
thus thorough staging with imaging, evaluation therapy agents commonly used to treat NSCLC
of the mediastinum, and bone marrow biopsy are include aspla tin, carboplatin, paclitaxel, docetaxel,
recommended. For patients with disease limited to gemcit^rii^ and etoposide. The addition of tar
the thorax, lobectomy (removal of one lobe of the geted therapies, such as bevacizumab (a monoclonal
lung) or pneumonectomy《removal of the entire antibody that blocks vascular endothelial growth
lung), followed by adjuvant chemotherapy and factor) or erlotinib (a small molecule inhibitor of
thoracic irradiation is the treatment of choice. In the enzyme tyrosine kinase, which is involved in
addition, patients with SCLC are at very high risk numerous cell cycling and survival pathways), has
for the development of brain metastases, and thus been shown to improve survival rates, and should
prophylactic cranial irradiation should be consid also be considered for patients without a contrain
ered. For patients whose disease is metastatic at dication to these agents.37- * Side effects from these
presentation, combination chemotherapy has been targeted therapies include an increased risk of
shown to improve their chances of surx iral?' The bleeding, hypertension, and renal toxicity.
most common chemotherapy regimen used for With the advent of targeted therapies, the man
treatment of SCLC is cisplatin and etoposide. When agement of many cancers, including NSCLC, is
given without concurrent radiation, these drugs are rapidly solving. As knowledge about both tumor
usually administered intravenously on a daily basis biology and treatment response improves, we are
for the first three days of a 21- to 28-day cycle, for increasingly able to recognize which tumors are
four to six cycles. most likrty to respond to a given therapy, thus
Non-small cell lung cancer accounts for about enabling the more individualized management of
80% of all lung cancers and includes squamous cell cancer patients. As an example, numerous studies
carcinoma^ Urge cell carcinoma, and admcKarci* have recently shown that patients whose tumors do
noma. For patients with operable NSCLC (smaller not contain a mutation in the gene k-ras, which is
lesions with limited or no nodal involvement), the
treatment of choice is lobectomy, although in some
cases bilobectomy or pneumonectomy is required.
In patients with high-risk histological features, 년앞 Take-Home Message
positive surgical margins, or more extensive disease The most common cancer
noted at surgery, postoperative chemotherapy or among men in the United States
chemoradiation is often recommended. Because of is prostate cancer, accounting
the high risk of recurrence, surveillance with chest lor more than 25% of cancer
CT every four to six months is recommended after cases. In women, breast cancer is ttie most
completion of therapy. common malignancy, accounting lor rough
For patients with extensive local disease at the ly 28% of cancer diagnoses. However, the
time of diagnosis and those with tumors in certain most common cause of cancer death among
locations that are difficult to resect, treatment both men and women in the United States is
options may include surgery, chemotherapy, or lung cancer.
radiation, or a combination of modalities. Decisions
Diagnosis and Treatment of Cancer
known to be involved in cancer development and stay of chemotherapy for colorectal cancer was
progression, are more likely to rvspond to treat S-fluorouracil (5-FU). Newer regimens combine
ment with targeted therapy drugs such as erlotinib either intravenous 5-FU or capecitabine, an oral
and cetuximab.w As more information of this sort form of 5-FU, with newer chemotherapy agents
becomes avaibbk, we will be increasingly able such as oxaliplatin or irinotecan or targeted therapy
to provide certain treatments to patients who are such as cetuximab or bevacizumab. As with lung
most likely to respond、and to spare those who are cancer, emerging data suggest that cetuximab is
not likely to benefit from those therapies because particularly effective for patients in whom tumors
of their toxidties. do not have mutations of the k-ras g<;ene.'
Postoperative radiation therapy should be con
Colorectal Cancer sidered for patients with tumors that have invaded
into the muscle in the bowel wall or have perforated
Colorectal cancer is highly treatable and often cur the bowel wall, and in those with positive surgical
able when confined to the bowel; thus, screening for resection margins, in patienB with rectal cancer,
this disease is routinely recommended for people chemotherapy and radiation are often given con
over the age of 50. Colon cancers may be asymp currently and may be prescribed prior to or after
tomatic or may present with vague abdominal completion of surgical resection.42
complaints such as pain or bloating. Minor changes Local recurrences of colon cancer usually happen
in bowel habits or blood in the stool may also be at the surgicalor in adjacent lymph nodes.
seen; with right-sided lesions, chronic blood loss The most common sites of distant spread 五re the
may lead to symptomatic anemia. Left-sided lesions lung and liver. For patients with a single or few
may cause obstructive symptoms such as nausea or metastabc lesions, resection of metastatic lesions
vomiting. Very distal or rectal lesions can present may result in cure. Chemotherapy for advanced
with feelings of rectal fullness and urgency.40 disease is an evolving field, but generally involves
An initial workup for colorectal cancer should sequential or concurrent use of the agents described
include a digital rectal examination (DRE) and a previously for treatment in the adjuvant setting.
colonoscopy with a biopsy of any suspicious lesions. Patients with a diagnosis of colon cancer that
As with other cancers, tissue examination b required have completed therapy should be carefully
to confirm the diagnosis of malignancy. Staging monitored with physician visits and CEA testing
depends on degree of invasion into the bowel (if indicated) every three months initially, and then
wall, whether tumor is present in the regional lymph every six months. A foUow-up colonoscopy should
nodes, and whether there is evidence of distant be performed within a year of diagnosis, and then
spread of disease. A CT scan may aid in determin every one to five js depending on whether addi-
ing the extent of disease. OFcuKMrmbryonk Antigen ticwial p lesions are present. In patients
(CEA) is a blood marker that may be elevated in at high pt recurrence, surveillance may also
patients with colorectal cancer. CEA should be scan of the abdomen.45
checked at ba»dine; if elevated, it can be monitenvd
postoperatixêly fO【evidence of disease recurrence.®
Primary treatment for colorectal cancer involves
surgical excision of the tumor and the evaluation of Take-Home Message
adjacent draining lymph nodes and surrounding Treatment for cancer can in
connective tissue. The surgical procedure of choice volve local therapy (usually sur
is usually a hemicolectomy; in some cases, thi»pro gery, radiation, or both) or sys
cedure can be performed laparoscopically.41 Resec temic therapy (chemotherapy,
tion of rectal tumors generally requires a surgical hormonal treatment, or targeted therapy).
margin free of tumor. In some cases, a sphincter Newer targeted therapies exploit certain
sparing approach may be possible. known abnormalities present in tumors to
For patients with nodal involvement or tumors give the most effective treatment with the
invading the muscle, p»ostoperative chemotherapy fewest side effects.
may be considered. Prior to this decade, the main-
12 ACSMrs Guide to Exercise and Cancer Survivorship www.acstn.org
Cancer Recurrence modalities, and follow-up are important for pro

fessionals involved in the cart* of cancer patients
Warni 매 Signs and survivors.
Signs of cancer recurrence are generally related to References

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CHAPTER 2
Side Effects and

Persistent Effects
of Cancer Surgery
and Treatment
Tara Sanft, MD, and Melinda L. Irwin, PhD, MPH
following:
• Knowledge of the common side effects and symptoms of typical cancer treatments (surgeries,
chemotherapy, radiation, hormone manipulations, other drugs).
• Knowledge of the major long-term effects of treatment among childhood cancer survivors ttiat
may require careful screening and program adaptation tor these individuals.
• Knowledge of the common sites of metastases and ability to design and implement appropriate
exercise programs consistent with this knowledge.
• Knowledge of the signs and symptoms associated with r>ew-onset Jymphedema, and the
major cancer types associated with increased lymphedema risk (e.g.. breast, head, and neck
cancer).
• Knowledge of how cancer treatment may alter cardiovascular risk factors, and inappropriate
cardiovascular responses to exercise testing or training.
• Knowledge of the effect of cancer treatment on balance and mobility and the ability to develop
an appropriate exercise program that minimizes fall/iniury risk.
• Knowledge of cancer diagnosis and treatment effects on physiological response to acute
and chronic exercise, particularly with regard to physical deconditioning, body composition
changes, and range of motion.
16 ACSM's Guide to Exercise and Cancer Survivorship www.acsmorg
Despite advances in cancer therapy, approximately Most cancer patients receive surgery. This sur
500,000 adults die each year from cancer in the gery a)uld be minor (e.g., removal of a mole) or
United States? Recent research efforts have been major (e.g., removal of a large section of the colon).
directed toward tailoring cancer therapy based About half of cancer patients undergo ionizing radi
on patient and tumor characteristics, to optimize ation treatments. Radiotherapy may be delivered
efficacy and minimize toxicity. Given that many pre- or postoperatively, alone or 'vith concomitant
existing cancer therapies are costly and have sig chemotherapy. The mode of delivery, schedule,
nificant side effects that can result in long-term and frequency arv unique to the form of cancer; a
morbidity and even mortality, nonpharmacologic common schedule involves frequent appointments
methods of preventing cancer recurrence may over a defined time period (e.g., radiation therapy
offer an attractive addition to the currently avail five days per week for six weeks).
able treatment options. This may be especially The majority of cancer patients also receive che
true in patients for whom current therapies are motherapy, which is prescribed orally or delivered
less effective, such as those with so-called triple* intravenously on cyclical schedules. The type and
negative (estrogen, progesterone, and HER2/neu duration of treatment are individualized, lasting
negate) breast cancer, or those with early-stage from a few months to much longer depending on
colon cancer who have completed chemotherapy the type and sevrerity of both the cancer and the
but have a high risk of recurrence. Intervention® chemotherapeutic agents used (e.g., one day, or
directed toward improving quality of life and cycle, of chemotherapy followed by two weeks of
lessening feelings of depression, insomnia, and recovery; then one day, or cyde, of chemotherapy,
fatigue are particularly important because many and so on, for eight cycles).
cancer survivors suffer these problems and are HormcYial therapies, used most notably to treat
unaware of ncmpharm^cologic practices that may certain types of breast and prostate cancer, are in
help. Additionally, because people who have sur the form of dru표 therapy or surgery (e.g., removal
vived cancer have an incrvused risk for developing of the ovaries |onph<>rectomy] or testicles |orchiec-
cardiovascular disease, physical activity programs tomy]). Paherits taking oral drugs commonly take
may have a positive effect on this outcome as
them daily, sometimes for many years. Finally, a
welt2
growing number of targeted therapies are being
When designing an exercise program for those
developed for cancers that are tumor specific (e.g.z
who have completed treatment for cancer, fitness
trastuzumab [Herceptin), a monoclonal antibody
profcM讀onals must be familiar with the side effects
given to breast cancer survivors who overexpress
associated with cancer surgery and treatment, as
the HER2/neu receptor or exhibit gene amplifica
well as late effects (i.e., side effects that occur years
tion).3
after completing treatment). This chapter addrvsRC%
Fitness professionals need to remember that
the common side and late effects associated with
cancer therapies are constantly changing. To best
cancer surgery and treatment
evaluate a cancer survivor*s exercise tolerance and
prescribe a safe and effective exercise program,
Side Effects of Cancer the fitness professional needs to understand the

specifics of the clients diagnosis and the treatments
Surgery and Treatment received. A new client treatment form can be helpful
in this regard (see figure 2.1). Further, this informa
Side effects of surgery and treatment differ depend tion will need to be understood in the context of the
ing on the type of surgery (e.g., sentinel node biopsy person’s health (premorbid conditions) and fitness
vs. axillary node dissection; lumpectomy vs. mas levels prior to cancer diagnosis. Knowledge of the
tectomy) and treatment (e.g., radiation therapy, treatments received and the associated side effects
chemotherapy, hormonal therapy). Before we can help the fitness professional review the body
discuss the common side effects, we briefly discuss systems adversely affected, which may have posi
common surgeries and treatments offered to people tive or negative implications for exercise tolerance
diagnosed with cancer. and training.
Figure 2.1 New Client Treatment Form
Name:
Cancer type: Stage of diagnosis: 0 ■ II III IV
Date of diagnosis: Oncologist and date of last visit k
Treatment
1. Did you have surgery? 、fes No
Date of surgery: Site of sumry: W
Impairments from surgery (if any):
2. Did you have chemotherapy? Vtes No
Date of completion: 오 Name of chemotherapy: - 〜T__________
Are you cunently receiving chemotherapy? Ybs No
Name of chemotherapy you are cunently receiving:
Do you have persistent side effects from chemotherapy? Yes No
Please list any symptom(s) that is bothering you now that you believe could be related to you『 prior
chemotherapy (e g., numbness in fingers and toes, pain, depradMR):
3. Did you have radiation therapy? Yies No
8Re of radiation: 乂，厂 Date of radiation completion:
Impairments or symptoms from radiatiofi (if any):
4. Are you taking any medication currently related to your cancer treatment (e g., antihormonal therapy
for breast cancer (tamoxifen))? Yies No
Name of medication:
Please list any symptom you have now that you believe is related to your medk^tion:
(continued)
New Client Treatment Form (continued)
5. Please indicate if you have any of the following, and describe, as necessary.
Fatigue:
Depression: 스^^^『________________
Anxiety: _
Difficulty sleeping:
Weight gain or loss: _
Change in appetite:
Pain:
Shortness of breath:
Edema: _________________________________________________
Joint stiffness or pain: _
Fractures: .
Myalgias:
□ Musde weakness:— Q.
Lymphedema^
Neuropathy: _
From ACSM. 8D12. ACSMIl qukIv to «_iC4_ and c，c_r MvWwxWip (ChampagriL I: Human Kawtict)
The adverse side effects of cancer trvatments may

be acute, resolving over a period of days or weeks,
or they may be persistent, lasting years after treat
ment is completed. For the purpose of this chap
Take-Home Message ter, we use the term persistent effects, an umbrella
The Institute of Medicine (IOM) term that includes both long-term and late effects.
recommends that all cancer Long-term effects are side effects or complications
survrvors receive a survivorship that begin during or very shortly after treatment
care plan, a document detailing and persist afterward, and for which the cancer
treatments received, potential side effects, survivor must compensate. Late effects are distinct
and surveillance guidelines.4 Currently, re from long-term effects in that they appear months
search is being done to ensure that more sur or years after treatment completion (e.g., cardio*
vivors receive survivorship care plans. Sup myopathies after exposure to cardiotoxic agents).
vivors may complete their own survivorship Table 2.1 lists persistent effects of cancer treat
care plan, assuming they remember the ther ments, including effects on body systrms relevant
apies they have received, at the LiveStrong to exercise training: cardiovascuLir, musculoskel
websrte (www.livestrongcareplan.org). Once etal nervous, endocrine, and immune. It should be
the person has filled in the types and names noted that for persistent adverse effects of cancer
of treatments, this online program generates treatment, there may be predisposing host factors,
a document detailing potential long-term and including age, gender, and other comorbid health
late effects, which may be useful when plan*
ning exercise and rehabilitation programs.
Side Effects and Persistent Effects of Cancer Surgery and Treatment 19
TABLE 2.1 Persistent Changes Resulting From the Most Commonly Used
Curative Therapies
Hormonal therapy,
oophorectomy, or Targeted
Changes Surgery Chemotherapy Radiation orchiectomy therapies
Second cancers ✓ ✓
Fatigue ✓ ✓ ✓ 겨 ✓
Pain ✓ ✓ ✓ ✓ ✓
Cardiovascular changes: ✓ ✓ ✓ ✓
damage or increased CVD risk
Pulmonary changes ✓ ✓ ■卜
Neurological changes:
peripheral neuropathy ✓
Cognitive changes ✓ / ✓ ✓ ✓
Endocrine changes: reproduc ✓ / ✓ ✓ ✓
tive changes (e.g., infertility,
early menopause, impaired
sexual function)
Body weight changes Z ✓ ✓
(increases or decreases)
Fat mass increases ✓ ✓ ✓
Lean mass losses ✓ ✓
Worsened bone health ✓ ✓ ✓
Musculoskeletal soft tissues: / ✓ ✓ ✓
changes or damage
Immune system： impaired ✓ / ✓ ✓
immune function or anemia
Lymphedema ✓ ✓
Gastrointestinal system： ✓ ✓ ✓ ✓ ✓
changes or impaired function
Organ function changes ✓ ✓ ✓
Skin changes ✓ ✓ ✓ ✓ ✓
conditions, that synergize to influence the incidence survivors report persistent fatigue lasting months
and severity of adverse treatment effects. A recent to years after finishing therapy.6
IOM report on adult cancer survivorship offers an The National Comprehensive Cancer Network
in-depth review of the persistent effects of treat (NCCN) published guidelines to evaluate cancer-
ment/ related fatigue. The initial assessment includes
evaluating factors known to contribute to fatigue:
emotional distress, pain, sleep disturbance, medi
Fatigue cation side effects, hypothyroidism, and anemia. If
Cancer-related fatigue is defined as a distressing, these or other jxitentially reversible causes exist,
persistent sense of tiredness or exhaustion that is they should be treated with the intent of lessening
related to the cancer or its treatment.5 It is out of pro feelings of fatigue. If none of these factors are pres
portion to the level of recent activity and interferes ent or fatigue persists despite adequate therapy,
with functioning. Cancer-related fatigue is reported then nonpharmacologic interventions are recom
in 70 to 100% of patients undergoing treatment, and mended. Nonpharmacologic interventions include
activity enhancement with exercise programs, to tissue and nerves from the original tumor,
psychosocial interventions for stress and anxiety treatment-related injury from surgery, radiation
management, attention-restoring therapy, nutri or chemotherapy, and pain caused by noncancer
tion counseling, and sleep therapy. Pharmacologic conditions that may be a result of cancer treatment
inten*entions include the treatment of anemia and (e.g., cwteopowtic fracture as a result of bcme lo»s
the use of psychostimulants such as methylpheni from androgen deprivation therapy in a prostate
date (Ritalin). cancer patient).
Mechanisms of pain can be thought of as being
Sleep Disturbance mediated by two pathways: nociceptive and neu

ropathic.14 Nociceptive pain is caused by damage to
Sleq? disturbance is common among cancer survi- skin, muscles, connective tissue, and viscera. This
vors, and data are emerging on the prexralence of often results in either sharp, localized pain (somatic)
insomnia syndrome in this population? Insomnia or vague, cramp%* pain (visceral). Neuropathic pain
is defined as difficulty falling asleep, difficulty stay* results from inf ury to the central and peripheral ner
ing asleep (episodes of wakefulness lasting more vous systems and is often reported as a burning or
than 30 minutes), early-moming awakening, and shooting sensation. A thorough history and physical
nonrestorative sleep. In one large study of more Culmination can elicit the etiology of a patients pain
than 900 cancer survivors, 30% of survivas reported and further characterize the pain as nociceptive or
insomnia. About 20% of participants reported using neuropathic or containing elements of both.
sleeping pills or tranquilizers, and 60°® reported The approach to treatment of painkhould be indi-
taking naps at least "some of the time.**8 Recent xidualized to each patient and account for etiology,
data have shown that a yoga program may impnwe mechanism, and severity. The World Health Organi
sleep quality? zation (WHO) guidelines for cancer pain is a widely
accepted algorithm for tieatment that categorizes
pain by severity into fliild, moderate, and severe
pain.1' Interventions include acetaminophen and
Take-Home Message nonsteroidal anti-inflammatory medication for mild
■ A study of patients with lympho
pain and opioid^/ both weak and strong for moder-
ma randomly assigned partici-
ate and severe pain, respectively. Additionally, the
pants to Tibetan yoga or a wait
guidelines include a variety of adjuvant therapies
list control group. The patients
aimed at decreasing pain by manipulating a differ
in the yoga group reported less sleep dis-
ent mechanism contributing to the pain syndrome,
turbance, better sleep quality, and less use
thereby enhancing overall control. Examples of
of sleep medications.9 Yoga is a safe, non-
adjuvant mrdicatkms include antiamvulsant drugss,
pharmaoologic intervention that may benefit
tricyclic antidepressants, and muscle relaxants.
many survivors with sleep disturbance.
Nonphannacologic interventions indude massage,
physical therapy, hypnosis, and relaxation.
Pain Cardiovascular Changes

Although the data vary, most literature suggests Cancer therapy for multiple malignancies results in
that a significant percentage of cancer survivors both direct damage to the cardiovascular system and
experience pain attributed to their cancer or its indirect damage via increasing risk factors associ
treatment.Within this literature, several groups ated with cardiovascular disease. Treatment-related
of survivors at highest risk have been identified, effects can damage all parts of the heart including the
including those within five years of treatment, those muscle, electrical system, and valves. Symptoms of
who have undergone more intensive treatment, congestive heart failure include dyspnea on exertion,
and those with a lower socioeconomic status.* u edema of the lower extremities, and weight gain.
The etioiogy of pain in survivors can be attributed Specific chemcitherapy agents that can damage heart
to a wide variety of factors. These include damage muscle and lead to congestive heart failure include
anthracydines, taxanes, and trastuzumab. 416 The peak exerdse capacity, and shortness of breath.2**27
association between anthracydines and congestive Other studks in this population are ongoing.
heart failure is dose dependent, increases with age, Bleomycin is the most common chemothera
and is more common when combined with other peutic agent to cause pulmonary toxicity, most
therapies such as radiation. Decrea*M?d ej<*ction often in the form of pneumonitis, or inflammation
fraction, rhythm disturbance, and ventricular dys of the lung tissue. It is used to treat patients with
function are associated with these agents and can germ cell tumors in combination with etoposide
occur during treatment, within one year, or many and cisplatin (commonly referred to as BEP) and
years after the disease is treated.17-w Trastuzumab also in Hodgkin's lymphoma in combination with
(Herceptin) causes decreased ejection fraction and doxorubicin, vinblastine, and dacarbazine (com
can lead to ccxigestive heart failure, although the monly referred to as ABVD). Pneumonitis is a rare
incidence is very low and symptoms often reverse complication, with an incidence of less than 10% in
once therapy is discontinued.”* patients with germ cell tumor； but it can affect up
Radiation to the chest can cause cardiac toxicity to 30% of patients with Hodgkin's lymphoma who
by increasing inflammation in the heart and sur may also receive radiation to an area of the lungs.
rounding tissues, which can lead to fibrosis and Multiple other cheniotherapeutic agents have been
scarring. The ultimate effect of this is restrictive associated with pulmonary toxicities.
cardiomyopathy, or a decreased ability of the heart Radiation pneumonitis can be seen in patients
to expand. Symptoms of restrictive disease include who havenceived radiation to the chest and lungs
shortness of breath and can be seen as late as 10 for variouh tumor types. The incidence of radiation
years after treatment.^ Radiation can also damage pneumonitis is also rare; it usually occurs one to
cardiac vasculature, resulting in an increased risk thrrr months after completing therapy and resolves
of cardiac ischemia and myocardial infarction.21 with no further dinical consequences.*-30 A rare
Patients who have received radiation to the chest but devastating long-term side effect of radiation
for lymphoma, breast cancer, and lung cancer air at 1、pulmonary fibrosis, which can result in severely
highest risk Many studies examining radiation side decreased lung capacity and eventual respiratory
effects involve large populations of patients treated failure.
decades ago with outdated radiation techniques.
Newer, more focused, and targeted radiation tech
Neurological Changes
niques have reduced the incidence of this side effect.
Numerous neuropathio syndromes are associated
with cancer and its treatment. For instance, the
Pulmonary Changes tumor itself may encase nerves, causing burning,
Pulmonary symptom* related to surgery, radia tingling, and electrical pain. After surgical resection
tion, and chemotherapy are not uncommon in of a malignancy, some patient experience phantom
cancer survivors; they are reported in 20 to 50% of pain or the sensation of pain in a nonexistent limb.
certain patient populations, including survivors Other patients experience persistent pain at the
of germ cell tumors, Hodgkin's lymphoma, and site of a surgical incision such as a lumpectomy or
breast cancer, as well as bone marrow transplant thoracotomy scar.
rvcipiente.2 Although sonw studies have identified Neuropathy is a loss of sensation (often described
abnormal pulmonary function tests in cancer survi as numbness) or pain (radiating, burning or tingling)
vors, it is unclear how significant these findings are associated with damage to peripheral nerves. Symp-
in th<* asymptomatic patient.22 ^Certain symptoms tcims of neuropathy an* oftm seen in association with
such as shortness of breath and decreased exercise cancer treatment, especially with taxanes, vinca alka
tolerance may be seen, depending on the mode of loids, platinum agents, and thalidomide. Symptoms
treatment (e.g., surgical removal of a lung cancer usually start gradually and worsen with increasing
that includes removing a lobe of the lung). Small doses and duration of therapy. The prov ider may ask
studies in patients who had surgery for lung cancer if the patient has difficulty7 with specific tasks (e.g.,
found that inpatient pulmonary rehabilitation pro picking up a coin from the counter or buttoning a
grams have positive effects on functional ability. shirt) to assess the severity of the neuropathy.
Neuropathy may or may not resolve after ther can be compromised. Among adults, the majority
apy, and further studies are needed to delincate the of endcKrinc changes arc specific to the IcKation of
natural history depending on chemotherapeutic the tumor and the specific modality used to treat
agent, dosing, and underlying comorbid condi- it. For instance, patients with head and neck cancer
Multiple neuropathy prevention strategies often rt?ceive radiation as part of curative therapy.
have been studied without success?2 Treatment As a result, hypothyroidism is a common side effect
includes anticonvulsants such as gabapentin and and can be seen years after complehon of therapy *
pregabalin, which have shown mixed evidence 41 Symptoms of h>*pothytoidism include fatigue,
of effectiveness.나 34 Alternatives include tricyclic weight gain, constipation, depression, and weak
antidepressants, lidocaine patches, and opioid ness. Detection and treatment with thyroid hormone
analgesics. Nonpharmacologic treatments include rvphcement con reverse these symptoms entirely.
transcutaneous electrical nerve stimulation (TENS) Reproductive health can be threatened during
and physical therapy. cancer treatment, and chemotherapeutic agents
Ototoxicity is a common side effect in patients such as alky la tors (e.g., cyclophosphamide) can
treated with cisplatin chemotherapy. It may be induce infertility in both men and women. Prema
characterized by high-frequency hearing loss or ture ovarian failure can cause hot flashes, vaginal
tinnitus, or a perception of sound with an absence dryness, and osteoporosis. Alkylating agents used
of external sound. Researchers analyzing quality of to treat testicular cancer can also cause infertility,
life after adjuvant chemotherapy* in patients with but this usually reverses two to three years after
early-stage lung cancer found that hearing scores completion of therapy.
were significantly worse compared to those who did Many cancer survivors experience declines in
not receive chemotherapy. Poor hearing persisted bone health. Treatment of various malignancies
even after nine months?' Long-term hearing loss includes steroids, either as part of the treatment
has been reported in survivors of testicular cancer, plan or for symptomatic control of nausea and
with persistent symptoms reported in up to 20% of vomiting. Steroids are associated with osteoporosis
survivors.*17 and increased fractusc risk. Additionally, prema
Other neurological complications of cancer ture menopause caused by surgery, radiation, or
therapy include a phencimcnan described as chemo systrmic therapy can lead to bone k«s，osteopenia,
brain—a neurological decline after systemic chemo and osteoporosis. Endocrine therapy used to treat
therapy. Subjectively, many cancer survivors report breast and prostate cancer accelerates bone loss, and
feeling more forgetful and experiencing an inability bone mixMsrai density is monitored as part of rou
to concentrate and intermittent confusion. Objec tine care while the person is on these medications,
tively, patients who have received chemotherapy sometimes for years. Osteopenia and osteoporosis
have scored lower on neuropsychological tests puls survivor* at risk for fracture, which can lead to
compared to healthy controls, although no overall debilitation, pain, and financial burden. Treatment
statistically significant difference has been found.*- includes dietary supplementation of vitamin Dand
Hw symptoms of chemobrain correlate better with calcium, weight-bearing exercises, and bisph(«ipho-
measures of depression and anxiety than they do nate therapy.
with neuropsychological test results. Studies are
necessary for further describing the incidence, Musculoskeletal Changes
characteristics, risk factors, and treatment of this
distressing symptom. The musculoskeletal system can change in many
ways after cancer treatment. For instance, treat
ment of breast cancer with endocrine therapy such
Endocrine Changes as aromatase inhibitors can cause pain in the small
Effects of cancer treatment on the endocrine system pints in as many as 47% of patients, and joint stiff
have been understood for decades. The pediatric ness occurs in as many as 44%, In some patients,
survivorship population is the most commonly stud joint symptoms are so severe they cannot complete
ied. Pediatric survivors are often the mast severely the reccxnmended duration of treatment (usually
affected because their growth and development five years of therapy). A recent study showed that
acupuncture significantly reduced symptoms of the area around the tumor. Lymphedema is associ
aromatase inhibitor-rHated arthralgias.41 A study ated with limb heaviness, aching, and numbness,
led by Dr. Melinda Irwin at Yale University is which results in chronic pain and can lead to a loss
currently examining the benefit of resistance and of function and an increased risk of infection.
aerobic exercise on attenuating joint stiffness and The majority of patients who report lymph
other side effects of aromatase inhibitors in women edema are breast cancer survivors, although
with breast cancer. patients with a history of ovarian, colon, pros
Androgen deprivation therapy (ADT) as treat tate, and testicular cancer can experience lower-
ment for prostate cancer causes changes in the extremity lymphedema. The majority of patients
composition of lean body mass，with a decrease seen develop lymphedema within the first couple of
as early as 36 weeks after starting therapy.44 ADT years of diagnosis, although late-onset swelling
also increases fat mass, which predisposes men to can occur many yeacs after surgery.*5 Treatment
cardiovascular disease, type 2 diabetes, and prema includes manual Emphatic drainage, compression
ture death.44 Considering that one in six men will be garments, exes0se/tnd skin care. Historically,
diagnosed with prostate cancer in his lifetime, and breast cancer survivors have been encouraged to
that the five-year survival is nearly 100*%*/ the mus avoid heavy lifting (greater than 5 lb，or 2.3 kg) with
culoskeletal changes that occur with treatment have the affected arm, but recent evidence suggests that
implications regarding physical functioning, which controlled, progressive resistance training does not
can affect strength, productivity, and independence. adversely affect the limb with lymphedema.An
updated consensus on the approach to survivors
Immune Function Changes with lymphedema is needed in light of this recent
evidence.
Lymphedema refers to swelling in a limb as a mult
of lymphatic obstruction or destruction. This usually
occurs after a surgical resection of a tumor，when Gastrointestinal Changes
there is damage to the lymphatic system draining The gastrointestinal system can be disrupted in
various ways following cancer treatment. Manage
ment of pain with opioids can cause constipation;
radiation to the head and neck can cause esophageal
，—한 Take-Home Message strictures, which impair eating; and radiation to
심_ A common misconception is the abdomen or pelvis can result in malabsoq^tion,
that women who have had adhesions, and diarrhea. Although surgical tech
breast cancer surgery are re niques have improved, survivors with colorectal
stricted in terms of exercise cancer who have had surgical resection can experi
with the arm of the affected side. This is not ence chronic diarrhea, fecal incontinence, urgency,
true, as highlighted by research that showed and incomplete evacua tion.M A3 In a survey of colon
that slow〜 progressive weightlifting did not cancer survivors at least five years from diagnosis,
increase limb swelling in women at risk for 49% of respondents reported chronic diarrhea, and
breast cancer-related lymphedema. The 16% reported three or more bowel movements
women in the supervised exercise group daily.*4 These findings have implications on a cancer
received two sessions weekly for 13 weeks. survivor’s mobility, productivity, and quality of life.
Each session lasted 90 minutes and consist
ed of upper-body and lower-body resistant
exercises. Three sets of each exercise were
Organ Function Changes
performed at each sessicxi. 10 repetitions In addition to changes in multiple anatomical sys
per set. Weight was increased by the small tems, cancer treatment may permanently impair
est possible increment after two sessions of specific organs. Often, the functions of these organs
completing three sets of 10 repetitkxis with are monitored before, during, and immediately after
no change in arm symptoms.* treatment. Long-term monitoring for organ damage
is used on an individual basis.
Renal Damage especially if the patient received multiple transfu

sions before 1993.
Platinum-based chemotherapy and regimens
containing ifosfamide or methotrexate can cause
significant renal damage, or nephrotoxicity. During Skin and Hair Changes
the treatment phase, renal function and electrolytes
Skin and hair changes after cancer treatment include
are mcmitored closely, and dose adjustments are
generalized loss or thinning of hair and skin discol
made based on changes in glomerular filtration
oration from rAdiabon or chcmothrrapcutic agents.
rate (GFR). Long-term renal impairment is associ
In patients who have had stem cell transplantation,
ated with hypertension and an increased risk of
graft-versus-host disease (GVHD) can affect all
cardiovascular disease.
organs, including the skin. Changes «fccn in this dis
Multiple studies looking at the long-term effects
ease include skin tightening, diffuse maculopapular
of nephrotoxic chemotherapy in the pediatric cancer
rash, dryness, and ulcerations. The treatment of
survivor population suggest that the majority of
GVHD of the nkin includes immunosuppressive
cancer survivors have normal renal function as dis
agents, such as high-dose steroids. Topical steroids,
tant as 10 years after treatment, with less than 5〜 of
high-dose long-wave ultraviolet radiation (UVA1),
the population having abnormalities in dtactnilyte
and photochemotherapy (PUVA) may be used to
balance.'5, The Children's Oncology Gxoup (COG)
reduce the severity of skin problems.
recommends yearly blood pressure and urinalysis
Basal cell carcinoma is a skin problem that can
monitoring to evaluate for hyp<*riensi<)n and pro
be seen in survivors who have received radiation.
teinuria, respectively. They also recommend a one
In a survey of more than 2/)00 survivors of child
time check of renal function, which should include
hood cancer, basal cell carcinoma was found in 11%
a check of bkxxl urea nitrfn (BUN), creatinine,
of patients who remained in remission from their
and electrolytes. If the levels of these elements
primary cancer.5*4 Although basal cell and squamous
are abnormal, ongoing management needs to be
cell carcinomas of the skin (collectively referred to
considered.”
as nonmelanomatous skin cancer) are thought to be
Liver Damage nonaggressive and highly treatable, multiple recur
rences are common,**1 requiring expensive excisions
Acute liver damage can occur at any time during
that can leave disfiguring scars.
chemotherapy; however, the long-term side effects
that anticancer treatment has on the hepatobiliary
system are not well understood. The Children's
Oncology Group (COG) performed a literature Recurrence,
review on the late effects on the hepatobiliary
system in children and adolescents with cancer.w
New Primaries,
The potential effects of therapy on the liver include
the formation of fibrosis, which can lead to cirrho
and Second Cancers
sis; portal hypertension; and the development of Perhaps one of the most daunting concerns for
hepatocellular carcinoma. Additionally, patients cancer survivors is the possibility of recurrence.
requiring frequent blood transfusions are at risk The National Comprehensive Cancer Network
for viral hepatitis and iron overload; and patients (NCCN) has guidelines on monitoring patients for
requiring total parenteral nutrition (TPN) may recurrent disease. Outside of clinical history, physi
develop cholestasis. Those patients who have cal examination, and certain screening tests such as
had stem cell transplantation are at risk for graft- mammography, colonoscopy, and prosta te-specific
versus-host disease, which can involve the liver. antigen (PSA》, there are not specific tests that can
The follow-up care guidelines put forth by the definitively demonstrate whether a patient has
CCXj apply to survivors of childhood cancers, but recurrent disease. Understandably, symptoms that
one-time monitoring of liver enzymes and biliru may seem benign in the patient without a history of
bin production is reasonable in adults who have cancer can be very worrisome in a cancer survivor.
received hepatotoxic chemotherapy. A physician For instance, low back pain is the fifth most common
should also consider screening for viral hepatitis. reason for a visit to a doctor in the United States,
and most symptoms improve substantially within 5. Mock X et al. NCCN practice guidelines for cancer-
the first month?1*，In a patient with a history of related fatigue. Oncology (WilliMon Park). 2000;
breast or prostate cancer, however, back pain may 14(11A) 151-M1.
be the first symptom of recurrence and could herald 6. Curt G, et al. Impact of cancer-related fatigue on
the lives of patient、New finding；* from the Fatigue
serious conditions such as malignant spinal cord
Coalition. 2000； 5(^953*360.
compression. For these reasons, practitioners must
take the cancer survivor’s history into account when 7. Palesh OG, et al. Prevalent, demographics, and
psychologicjI dkMOciatiom of sleep disruption in
evaluating seemingly benign complaints.
patients with cancer: University of RiKhester Cancer
In addition to recurrence, survivors may worry Center-Community Ctinical OKology* Program. / Clin
about the development of a new malignancy, either Oncd 201Q; 2«2hTC-298
related to the environmental factors that put them at 8. Davidson et al. Sleep disturbance in cancer
risk for the original cancer (e.g., smoking increases patienu. 직乂dMat 2002； 54(9)： 1309-1321.
the risk of head and neck as well as lung cancer) 9. Cohen L et al. fSychologkÎ adjuMment and »levp
or to the treatment for the original cancer (certain quabh' ina randucni2ed trial of the effects of a Tibetan
chemotherapies are associated with bone marrow yoga intervention in patients with hmphoma. Cancer.
■ 2004; 100(10): 2253-2260.
damage that can lead to myelodysplasia and acute
leukemias). Knowing the survivor's treatment 10. Ferrell BR, et al Quality of life in long-term cancer
history can help providers understand the risk of survivors. Oncol Nurs Forum. 1995; 예 915-922.
developing additional malignancies. 11 Deimling GT et >1 The health (、f <4dcr-adult long
term cancer survivors. Ginarr Nttfs. 2005; 28(6)： 415-
424.
Summary 12 Keating NL, et al. Physkal and menUl health status

of older long-term survivors. / Am Gerurtr Soc.
Cancer survivors are a unique medical population 2005; 53(12): 2145-2152.
with a wide variety of treatment options (surgery, 13. Hudwin MM, ct ci. Health status of jdult long-term
radiation, and chemotherapy) that put them at risk survivors at ^likUuM»d cancvr: A report from the
Childhood Cancer Survivor Study. IAMA. 2003;
for both short- and long-term side effects. The actual 290(12)： 15«il592.
risk to each person depends on the type of cancer,
the treatments received, and other factors relating 14. CaractoM A, Weinstein SM. Classificatum of cancer
paih syndromes. Oncology (Williston Park). 2001;
to genetics, lifestyle'and behavior. Awareness that
<5(12): 1627-1640, 1642; discussion 16421643, 1646-
a cancer survivnr may have a variety of Icmg-term ，广 1647.
effects after treatment will help providers tailor

15. Stfemsward J, Colleau SM, Ventafridda V. The World
treatments to address these effects as well as work Health Organization Cancer Pain and Palliative Care
on modifying each surv4vor*s risk with the goal of Program. Past, prvMmt, and future. / Pain Sympiurft
not onhr reducing the risks of nwrbidity, mortality, Mmtgt. 1996; 12(2): 65-72.
or recurrence, but also enhancing the quality 6f life. 16. Hvquct O, ct al. Subclinical Late cardiomyopathy after
doxorubicin therapy for lymphiinvi in adult策 / Clin
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CHAPTER 3
Lifestyle Factors
Associated With
Cancer Incidence,
Recurrence, and
Survival 參
Heather K. Neilson, MSc, and Christine M. FriedenreicK PhD
following:
• Knowledge of how lifestyle factors, including nutrition, physical activity, and heredity, influence
hypothesized mechanisms of cancer etiology.
29
Age, sex, and genetics are well-known, unavoid (in postmenopausal women), endometrium, and
able risk factors for cancer; however, modifiable kidney.'* In 30 European countries in 2002< over
risk factors also exist. Remarkably, roughly one weight and obesity alone were responsible for an
third of cancer deaths worldwide may actually be estimated 10 to 40% of these five cancers/ whereas
preventable.1 Generally speaking, for Americans, in the United States for a similar time period, 21
the most important behaviors for reducing cancer to 57% of these cancers could be attributed to
risk are limiting exposures to UV radiation, not overweight and obesity10 (see figure 3.1). It is also
using tobacco, avoiding infectious agents, exer- probable, but less certain, that higher BMI increases
cising, eating well, and maintaining a healthy the risk of gallbladder, liver, pancreatic, and ovar
body weight.2 This chapter provides an overview ian cancer; aggressive prostate cancer; and possibly
of the scientific literature on the effect of body other cancers as weW.% 11 u
weight, diet, and physical activity on the risk of Not only is body weight an important cause of
developing cancer and, after a cancer diagnosis, cancer, but also emerging evidence implies that it
the effect of these factors on cancer recurrence and may also be a key factor in carterr prognosis. For
survival. example, studies over the past decade suggest that
obesity increases the risk of recurrence or death, or
both, from breast cancer?* *? colon cancer,■- ** pos
EffecLofJody Weight sibly prostate cancer,®-21 and maybe other cancers
as well. In one American study in which more than
In developed countries, smokings alcohol use, 900,000 aduitB were followed for 16 years, higher
and overweight (body mass index |BMI| of 25.0 BMI was associated with increased mortality rates
to 29.9 kg/m:) and obesity (BM1 2 30.0) are likely from cancers of the esophagus, colon and rectum,
the three most important^ preventable risk fac liver, gallbladder, pancreas, kidney, stomach (in
tors for cancer,1 whereas obesity is considered a men), prostate, breast (in women), uterus, cervix,
major risk factor for cancer death? 4 Hence, as the and ovary, as well as non-Hcxigkin's lymphoma,
obesity epidemic grows, widespread increases in multiple myeloma, and leukemia (in men).1 The
cancer incidence and mortahty can be expected. following sections discuss five canoers that are con
Current evidence supports the fact that higher vincingly associated with body weight in terms of
BMI is related to increased risks for cancers of cancer risk, as well as the related evidence on cancer
the esophagus (adenocarcinoma), colon, breast recurrence and survival.
UnMed Slates
Figure 3.1 Percentage of adult cancers attributable to overweight and obesity in the United States and
European Union. The population attributable fraction is the percentage of disease in a population that
would be prevented if a given risk factor (e.g., overweight and obesity) were eliminated.15
Data from Cate and Kaaks 2004,*
Lifestyle Factors Associated With Cancer Incidence, Recurrence, and Survival 31
Breast Cancer colon cancer than for rectal cancer,13155 although

an increased risk of rectal cancer with higher BMI
It is now well established by extensive research might exist in men■田
that postmenopausal breast cancer risk is higher Much less research has addressed colon cancer
for overweight and obese women than for post prognosis in relation to BMI, but the overall evi
menopausal women of normal weight4 and that the dence generally supports poorer outcomes in those
risk tends to increase with increasing BMI." Weight who are obese.21 One study, for example, found
gain abo increases risk whereas intentional weight colon cancer deaths and recurrences (combined
loss seems to reduce risk,22-14 but these effects may with second primaries) to be more common in
only occur in nonusers of menopausal hormones. patients with BMT > 35 compared to those of normal
Among premenopausal women, generally the weight.** In another study, deaths from colorectal
opposite holds true because higher body weight cancer were more likely to occur in patients with
has been associated with a decreased breast cancer higher percent body fat, higher body weight,
risk.2* M and larger waist circumference?* Another study
Interestingly, energy balance (Le.z energy intake showed that obese women diagnosed with colon
versus energy expenditure) could be even more cancer had a higher average mortality rate over
important than body weight in determining a time than women of normal weight diagnosed
woman’s risk of breast cancer. One large research uith colon cancer, but this same association was
study showed that postmenopausal breast cancer not found for men?4 Despite these relatively recent
risk was doubled when women with the highest findings, more research is needed before any firm
BMI, highest caloric intake, and least amount of conclusions can be drawn surrounding BMI and
physical activity were compared to physkally active colon cancer prognosis.
women with the lowest BMI and caloric intake
Similar effects may occur in premenopausal breast
cancer as well.2*
Endometrial Qancer
Body mass index has also been examined con The strongest and most consistent evidence sup
siderably over the past 30 years as a hypothesized porting an association with elevated BMI exists for
prognosticator for breast cancer survivors. In endometrial cancer. The proportion of endometrial
general, most epidemiologic evidence suggests cancer in the United States attributed to overweight
poorer outcomes with higher BMI in both pre- and and obe&ity was estimated at 57%/° and more
post men opa usal women. Most studies associate recently in Europe at 40%, In other words, more
overweight and obesity, and also postdiagnosis than half of all endometrial cancer cases in the
weight gain, with an increased risk of breast cancer United States have been attributed to body weight
and shortened survival * (see figure 3.1), making obesity a key modifiable
risk factor for endometrial cancer.1' Our own review
of the scientific literature describing more than
Colon Cancer 40 studies of BMI and endometrial cancer risk in
The overall evidence from research studies is women revealed a two- to fourfold increase in risk
now convincing that higher BMI increases the when groups of women with the highest BMI were
risk of col()n and colorectal cancer, with the asso compared to those with the lowest BMI. The lowest
ciation being somewhat stronger in men than in BMI category was hpically defined as BMI < 25 or
women.31-33 Most studies of colon or colorectal another cut-point within the normal range for BMI
cancer suggest an increasing risk with higher BMI. USSto24 9).
In addition, when comparing groups with the In most studies, risk tended to increase with
highest BMI to those with the lowest BMI, the risk increasing BMI? One group estimated that for
is appmximately doubled. Moreover, the relation every 5 kg/m2 increase in BMI, the risk of endome
with BMI does not seem to depend on the subsite trial cancer increases by 60%; however, in women
of the tumor (i.e., proximal or distal colon).31-32 with BMI > 27 kg/m2 the increase could be much
Overall, study findings on BMI have been more greater.u In addition, the association was stronger
consistent and suggest a greater increase in risk for in women who never used hormone replacement
therapy.* Some evidence suggests that substantial analysis of research studies, every 5 kg/m2 increase
weight gain over the adult lifctunc (from age 18 to in BMI was associated with a 52 to 54% higher risk
age 75》also increases risk; however, this effect may of esophageal adenocarcinoma.4* In contrast, higher
only occur in women who never used menopausal BMI appears to decrease the risk of squamous cell
hormonal therapy.17 * carcinoma and possibly also prolong survival of
Although much less research has addressed BM1 this disease.* Studies that examined the effect of
and long-term prognosis for endometrial cancer, BMI on survival and recurrence from esophageal
some studies folknving cndomrtrul cancer patients adenocarcmoma are very sparse, but one study that
have related higher BMI to worsened prognosis. followed patients following esophagectomy found
Those studies showed that obesity, and particu no association with BMI广 More research is needed
larly morbid obesity (BMI > 40》,、in women with to confirm thone findings.
endometrial cancer may be linked to higher risk of
death.** However, because other studies have not
found obesity to be a negative prognostic factor in
Biologic Mechanisms
endometrial cancer,21 more research is needed to The reasons overweight and obese people are at
clarify the assexiation. higher risk for various cancers are not yet fully
understcxxl; h《nvev«, many hypothec，have been
proposed (see table 3.1 In general, the most
Kidney Cancer y well-studied mechanisms involve sex steroids,
Convincing evidence implicates obesity as a key insulin and insulin-like growth factors (IGFs),
risk factor for kidney cancer, particularly lenal cell and adipokines/1 which are biologically active
carcinoma. Some studies suggest a stronger link substances derived from fat (e.g., leptin). Future
with BM! in women than in men/ Our own review studies in humans will be extremely important for
of the scientific literature revealed relatively con testing these mechanisms and others, and also for
sistent results across studies and, overall, a two- to understanding how mechanisms interact to alter
threefold increax? in risk for those with the highest cancer risk.
BMI compared to those with the lowest BMI. Risk
also tend5 to increafe with increasing BMI, with RecdiTimendations for Body
an estimated 5 increase in risk for every
unit increase in BMI (1 kg/m2) in both men and
IQêight and Cancer
women. *,-43 In 2006 the American Cancer Society published
Paradoxically, recent studies of recurrence and guidelines on nutrition and physical activity for
sun ival from renal cell carcinoma have generally preventing cancer13 and also for cancer survivors.52
revealed better or equivalent outcomes for ©ver- With respect to body weight it recommended the
weight and obese patients compared to normal following:
weight patients.*3"45 However, given the small
• For cancer prevention: Maintain a healthy
number of studies that have investigated the rela
body weight (BMI 185 to 24.9) throughout life
tion between BMI and kidney cancer prognosis,
by balancing caloric intake with physical activ
more long-term studies are needed to confirm these ity, avoiding excessive weight gain throughout
findings. life, and achieving and maintaining a healthy
weight if currently overweight or obese.13
Esophageal Cancer • For cancer survivors: Throughout the cancer
continuum, strive to achieve and maintain a
Present evidence suggests that higher BMI increases healthy weight52
the risk of esophageal adenocarcinoma,* 分 espe
cially in those with abdominal obesity.* An esti Furthermore, the World Cancer Research Fund
mated 52% of incidences of esophageal adenocar and the American Institute for Cancer Research rec
cinoma in the United States have been attributed ommend that for preventing cancer, people should
to overweight and obesity10 (see figure 3.1), and avoid increases in wai»t circumfercfKc throughout
approximately 40% in Europe? In a combined adulthood?
TABLE 3.1 Hypothesized Biologic Mechanisms Possibly Explaining the

Increased Risk of Cancer in Overweight and Obese People
Type of cancer Effects of overweight and obesity
Breast cancer T estrogen. T testosterone. 丄 SHBG
T leptin, i adiponectin, T insulin，? IGF； T cholesterol k'
Immune system dysfunction
T mflammalory cytokines
Colon cancer T leptin, T insulin, ? IGR T cholesterol
T inflammatory cytokines
T oxidative stress
Endometrial cancer T estrogen. T testosterone. 1 SHBG
T leptin. T insulin. T IGF, T dxMesterol
Kidney cancer T estrogen. T testosterone, I SHBG
T renal atherosclerosis
T hypertension-induced injury to renal tubules
T oxidative stress
Esophageal cancer T leptin. T insulin, T IGF, T cholesterol
T intra-abdominal pressure, T gastroesophageal reflux disease
T Barrett s esophagus
T esophageal transit time, T exposure tvne
AN cancers T pool of ce*s to undergo malignant transformation
T energy intake, 丄 physical activity
T concentration of growth factors or carcinogens in adipose tissue
type，with the evidence classified as convincing or

pnibable for colon, breast, and endocnetrial cancers;
Take-Home Message
possible for prostate, ovarian, and lung cancers;
There is now strong evidenoe
and null or insufftcient for other cancers?1 There
that increased body weight
is also increasing evidence that physical activity
and body mass index, and high
improves some health indicators and quality of
waist circumference, are related
life after diagnosis^ although there have not
to an increase in risk of several cancers as
yet been any reported clinical trials on the effect of
wel as possiMy being associated with poor
postdiagnosis physical activity on the risk of cancer
er chances of survival after cancer. People
should be advised io maintain body weight recurrence or survival?2" ** Challmges of these
within a normal range throughout lite to re trials include the possibility of group differences
duce cancer risk and improve their chances in prognostic factors and treatments; the stresses
of survival after cancer. of diagnosis, treatment, and recovery on a patient's
ability to exercise; and the need for a large trial to
detect statistically significant differences between
exercise and control groups.
Effect of Exercise The following sections review the scientific

literature on cancer sites that have been studied
Considerable scientific evidence suggests that most extensively in relation to physical activity.
physical activity reduces the risk of several cancer Epidemiologic research relating physical activity to
ovarian57 * and lung cancers5** are described else were more physically active postdiagnosis. In addi
where (see citations noted here). It is noteworthy tion, in the Melbourne Collaborative Cohort Study,
that much of the epidemiologic evidence is based prediagnosis exercise was associated with better
on studies that used questionnaires to estimate disease-specific survival."
physical activity levels. Many factors must be con The largest prognostic study to date was con
sidered when selecting a questionnaire, including ducted in 832 men and women with stage III coion
its validity for the research question being asked. cancer.사 In that study 18 to 26.9 MET-hours per
week of postdiagnosis leisure-time activity k)w-
Colon Cancer ered the risk of cancer recurrence or death by 49%

compared with those who did less than 3 MET-
The most consistent and strong evidence for a role hours per week. Furthermore, significant trends
of physical activity in cancer etiology exists for were found relating increasing activity levels to
colon cancer. An average risk reduction of about 25 improved disease-free, recurrence-free, and overall
to 30% is observed in both mm and women who survival. A minimum of 18 MET-hours per week
undertake the highest level of assessed physical of leisure activity improved disease-free survival
activity compared to the lowest level of activity in rates regardless ot BMI, number of positive
studies that have examined these associations내 **' lymph nodes, chemotherapy type, age, or baseline
(activity levels were not uniformly defined). These performance status.
findings are likely to be independent of body weight
changes. There is evidence for a dose-response
effect with more benefit being observed for higher
Breast Cancer
levels of activity, as defined in each study. These Extensive research has been conducted on the etio
results have been observed in studies conducted logic role of physical activity in relation to breast
in a variety of populations around the world, using cancer risk, with the majority of studies concluding
varying methods for assessing physical activity and that women who are more physicaMv* active have
with various study designs. a lower risk compared to sedentiry women.''
Although 52 studies of physical activity and Across 73 studies, the average risk reduction was
colon cancer have been identifiedsome aspects of about 25°o for the highest wrsus the lowest activ
this etiologic association remain unclear including ity categories compared/® and there is consistent
whether the benefits of physical activity depend on evidence of a dose-tesponse effect, with greater risk
menopausal hormone therapy use, dietary intake, decreases observed with higher levels of activity.
or BM1. In addition, the time in life when physical AU types of actKity* are beneficial, with somewhat
activity is most beneficial for colon cancer preven- stronger effects observed overall for recreational
tkm is unkncvwn; greater risk reductions may result and houM’hold activity.5'1 As well, the effect appears
from higher actirfty levels over the lifetime as to be significant more often in postmenopausa I
opposed to more recent activity.*4 It is also unclear women and, on average, and is stronger in normal
whether physical activity has a differential effect on weight women, non-Caucasians, women without a
various regions of the colon， îmily history of breast cancer, and women who are
Based on the overall evidence from studies dF parous. Effects are also stronger for activity done
recreational activity, about 30 to 60 minutes per day over the lifetime or after menopause, activity of
of moderate- to vigorous-intensity physical activity moderate or vigorous intensity, or activity of longer
may be needed to lower colon cancer risk signifi duration (hours per week) *
cantly?1 An erven greater benefit for cokm cancer risk Based on previous research, at least four hours
reduction may exist for vigorous-intensity activity,13 per week of moderate- to vigorous-intensityr activ
but the magnitude of this benefit is unclear.*4 ity may be necessary to reduce risk significantiy.,s
Relatively recent research has been conducted on A few aspects of this association remain unclear,
the role of leisure-time activity in improving colon including whether the benefit of physical activity
cancer survival.代*"* Four cohort studies conducted depends on the histologic type of the tumor, the
by Meyerhardt and coUeagues" **all showed better hormone receptor status, and other molecular
survival among colorectal cancer survivors who aspects.
The role of physical activity in breast cancer cancer survivors"13 This study was able to achieve
survival has bcm examined in 15 observational more weight losu* and increased exercise levels in the
studies conducted thus fdr.n_M Eight of these studies intervention group than in the control group and
suggested that higher physical activity levels were demonstrated that this type of lifestyle intervention
associated with a significantly decreased risk of is feasible and could result in sustained behavior
breast cancer mortality'4*7*-'13 or overall mortality,**- change over a yearlong period.
implying that physically active people with breast
cancer may have improved prognosis with fewer
recurrences and deaths compared with sedentary
Prostate Cancer
survivors. The largest prognostic studies to date There is inconsistent exfidence regarding the associa-
were conducted in the Breast Cancer Family Reg between physical activity and pro«tatc cancer,
istry* and the Collaborative Women’s longevity with about one third (16 out of 42) of the studies
Study、* with each study enrolling more than 4,000 conducted thus far indicating a protective effect. "•
breast cancer survivors. The latter study found a ，A *^Tlw magnitude of the risk reduction is modest,
51% decrease in breast cancer mortality among on average around 9%/,s and there remains a lack of
the most physically active as well as e\idence for clarity on whether the benefit from physical activity
a dose-response effect of decreasing the risk of varies according to other factors »uch as age, race,
breast cancer death with increasing levels of total ^mily history, and BML The effect of physical activ-
recreational activity postdiagnosis.'** In the Breast ity may also be more restricted to advanced prostate
Cancer Family Registry study, all-cause mortality cancers. Some evidence is emerging that higher
was decreased by 23 to 29% in women who were levels of lifetime physical activity may decrease
recreationally active three years prediagnosis com prostate cancer risk.11*11,7 Both occupational and
pared to inactive women, whereas no association recreational activities have been associated with
was found with lifetime physical activity. decreased prostate cancer risk.
The inconsistency across prostate cancer studies
may be attributed to several factors. First, prostate
Endometrial Cancer cancer is a slow-growing tumor with a long latency
Twenty of the 25 published epidemiologk stud- period, and a large percentage of men die with
ies*-10* suggest a protective effect from physical evidence of undiagnosed prostate cancer. There
activity in endometrial cancer risk; no association fore, some studies may have been unable to detect
was reported in five studies.Kl시10 Overall, evidence a difference in physical activity levels between the
suggests about a 20 to 30% decreased risk for the cancer patients and the **healthyM control popula
most active versus the least active study partici tions because of latent, nonclinical prostate cancer
pants; also, activity of light to moderate intensih* amcmg the controls. Second, healthier, physically
may lower risk, whereas sitting time may increase active men may be more likely to be screened for
risk/' Despite these findings, recent reviews of prostate cancer, and hence more likely to be diag
this lik'raturr* u1, ,,a hav*c emphasized the m*cd for nosed, than lcs*» active men. As a result some study
further research studies that have more detailed populations might not have accurately reflected
assessments of lifetime physical activity and the general population of cancer patients, and true
that consider all types and parameters of activ risk rvducticxvs were attenuated. Finally, it has been
ity. Furthermore, it remains somewhat unclear hypothesized11' that studies including a greater
how independent this association is from BMI or proportion of screen-detected, early-stage prostate
whether this effect depends on menopausal hor- cancer cases might reveal weaker associations
mone therapy use. between physical activity and prostate cancer risk
No observational studies have been published on than studies of advanced prostate cancer. A study
the role of exercise in endometrial cancer survival, by Littman and aUleagues11* found a strong inverse
but one randomized controlled trial examined how association between physical activity and prostate
a six-month intervention of lifestyle counseling cancer risk in men with no history of recent PSA
could influence physical activity levels, dietary testing, but no association was found in men with
habits, weight loss, and quality of life in endometrial a history of recent PSA testing. Another study114
showed no difference in risk based on PSA screen tion, endogenous sex hormones and metabolic fac
ing history, casting dcmbt on this hypothesis. tors, inflammaticin, insulin resistance, and possibly
Only one observational study has reported on immune function, though less is known about this
physical activity and prostate cancer survival.11* In mechanism.120 Some mechanisms are hypothesized
that study of 之705 nonmetastatic prostate cancer to be common across nwst cancer sites, whereas
survivors from the Health Professionals Follow-Up others are specific to a subset of cancer sites. For
Study, men who engaged in leisure-time physical example, for colon cancer, physical activity pro
activity postdiagnosis had significantly lower risks motes a more rapid gastrointestinal transit time
of all-cause and prostate cancer mortality； signifi thereby reducing the length of time that the colonic
cant trends were noted, with increasing MET-hours mucosa is exposed to carcinogens. Some commonly
per week corresponding with greater reductions in hypothesized biologic mechanisms linking physical
risk. Men reporting at least three hours per week activity to cancer risk are summarized in table 3오
of vigorous activity (versus less than one hour per
week) had a 61% lower risk of death from prostate Recommendations for
cancer.
Physical Activity
The most current recommendations for cancer
Biologic Mechanisms prev ention and cancer survival related to physical
Physical activity likely has an effect on cancer risk activity have been developed by the World Cancer
through multiple, interrelated biologic mechanisms Research Fund and the American Institute for
that include, primarily, an effect on body composi Cancer Research in their 2007 report/ the Ameri-
TABLE 3.2 Hypothesized Biologic Mechanisms Possibly Explaining the

Decreased Risk of Cancer in Physically Active People
Type of cancer Effects of physical activity
Colon cancer 丄 body fat
丄 insulin, i IGF-1
X leptin, ? adiponectin
I transit time through bowel
T vitamin D
Postmenopausal breast cancer I body fat 베
I sex hormones
丄 insulin
丄 leptin. T adiponectin ►
T vitamin D
Endometrial cancer 丄 body fat
I sex hormones
丄 insulin, 4dGF-1
I leptin. T adiponectin
Prostate cancer X testosterone
i insulin, 丄 IGF-1
I leptin. T adiponectin
Most cancers I chronic low-grade inflammation
Improved immune function
丄 oxidative stress. T antioxidant defense, enhanced DNA repair
IQF-1 = maulin-lrtie growth taoor-1
can Cancer Society,13-52 and an American College

of Sports Medicine roundtable discussion.121 These
Effect of Diet
recommendations are similar, based on the largely
An unhealthy diet could account for up to 30% of all
observational epidemiologic research that has
cancers in developing countries2 and perhaps 35% of
examined the link» between physical activity and
cancer deaths in the United States）父 Hence, along
cancer risk Because very limited research has been
with tobacco use, diet is one of the most important
done on cancer survival, in general, these national
modifiable risk factors for cancer. Given the diverse
and intcmatkmal agencies arv recommending that
and complex nature of the human diet, however; it
the guidelines for prevention also be followed for
is also one of the most difficult factors to study in
survival with some treatment- and disease-specific
large human populations. Numerous instruments
mcxlificatkins.
for dietary assessment have been developed and
• For cancer prevention: Be moderately physi validated.123 As in physical activity assessment,
cally active, equivalent to brisk walking, the choice of instrument depends largely on the
for at least 30 minutes every day. As fitness intended purpose. A vaft body of epidemiologic
improves, aim for 60 minutes or more of mod research has addressed a wide array of research
erate, or for 30 minutes or more of vigorous, questions related ID cancer and diet in an attempt
physical activity every day. Limit sedentary to disentangle individual dietary effects. Here we
habits such as watching television? highlight some of the strongest associations identi
• For cancer survival: No specific recommen fied thu* far,17 although more associations will
dations have yet been prescribed for cancer undoubtedly emerge in the future.
survivors because research done on these
populations has been insufficient. Hence,
following the recommendations for cancer Sugar, Fast Foods, and Other
prevention and avoiding inactivity is likely Energy-Dense Foods
appropriate/ u 121 with specific adapta
tions based on disease and treatment - rela ted
High-calorie foods and drinks are suspected risk
adverse effects.u, factors for cancer given their contributions to weight
gain, overweight, and obesity. The risks deriv
ing from specific aspects of an energy-dense diet,
however, are not as dear. Foods containing high
세g參 Take-Home Message amounts of sugar, for example, may be associated
■ Strong evidence suggests that with increased colorectal cancer risk, and biologic
physical activity reduces the mechanisms have been proposed, but the overall
risk of colon, breast, and endo evidence in humans is currently limited and merely
metrial cancers; the evidence suggestive?
for other cancers is more limited. The rote of In terms of fat intake, evidence from a substan
physical activity in cancer survival is emerg tial number of human studies has provided only
ing, and there is increasing evidence that limited, but suggestive evidence for increased risk
physical activity may increase the chances of cancers of the lung, breast, colorectum/ and
of survival of breast and colon cancers. Al possibly prostate.124125 Despite plausible biologic
though the optimal type, dose, and timing mechanisms for these cancers, the overall findings
of activity are not entirely clear, patients can surrounding fat intake and cancer incidence are
be advised to aim lor 60 minutes or more of inconsistent. Notably, dietary fat has been studied
moderate, or 30 minutes or more of vigor in relation to breast cancer recurrence and survival
ous. physical activity every day and to limit in two large randomized controlled trials. Findings
sedentary behavior. The risks associated from the Women、Intervention Nutrition Study12*
with specific cancers and cancer treatments and the Women's Healthy Eating and Living study127
should be considered when prescribing ex have suggested limited prognostic gain from low
ercise to survivors. ering dietary fat, although there may be some
decrease in recurrence rates for certain subgroups
of postmenopausal women. More limited evidence tive stress and DNA damage, and the ability to alter
suggests that the aggressiveness of prostate tumors the activities of carcinogen-activating enzymes arc
and deaths from prostate cancer may be related to just a few possible mediating pathways to preven
higher total and saturated fat intakes.128 tion. Higher intake may also favorably alter immune
function, infLmun.ituui, and cellular growth.1 m
Fruits and Vegetables

A plant-based diet rich in fruits, vegetables, and
Fiber
whole grains is continually recommended for the According to one international report on cancer
prevention of various cancers? ’，l3,52 In a com prevention广 a diet high in fiber may well reduce
prehensive review of published literature on this the rittkof colorectal cancer. Yet at least one pooled
subject, a variety of fruits and vegetables appeared analysis of research on this subject found no effect
likely to prevent cancer, althouî the evidence was from fiber beyond the effects of other dietary risk
not fully convincing (sec table 33)? factors.*M Part of the difficulty in studying fiber
Compared to cancer incidence, far fewer stud intake in humans may be that intake is too low to
ies have examined fruit and vegetable intake in obser\re any benefit.138.136 The Polyp Prevention
relation to cancer prognosis. Very limUed data Trial, conducted in the United States, explored the
support a decreased risk of recurrence or progres effect of increasing dietary fiber intake over four
sion of prostate cancer, for example, with higher years (and also lowering fat and increasing fruit
intake of tomatoes or lycopene.舞Vegetable intake and vegetable intakes) in people who had pre%4-
has been linked to longer survival from ovarian ously experienced one or more colorectal adenomas.
cancer130 and advanced lung cancer,132 but again, Adenoma recurrence was significantly lowered
these findings are vety preliminary. The effects on among the most compliant study participants,아
breast cancer prognosis are also unclear.17 In the implying that a high-fiber diet may also lower the
Women's Healthy Eating and Living randomized risk of colorectal cancer recurrences.
controlled trial of breast cancer patients, long-term The reasons that fiber may be protective are
adoption of a low-fat diet high in fruits, vegetables, unclear, but several mechanisms have been pro
and fiber had no effect on breast cancer recurrence posed? High fiber intake favorably alters the qual*
or survival?” ity of the feces by diluting its contents, increasing
Fruits and vegetables could prevent cancer its weight, and shortening transit time through the
through multiple, interrelated mechanisms. Prom수 colon. The outcome of these effects is decreased
tion of a healthy body weight, prevention of oxida contact between potential fecal carcinogens and
TABLE 3.3 Fruits and Vegetables That Probably Prevent Cancer

Fruits and vegetables Cancers probably affected
Nonstarchy vegetables Stomach, esophagus, mouth, pharynx, and larynx
Allium vegetables Stomach
Garlic CoIorectum
Fruits Lung, stomach, esophagus, mouth, pharynx, and larynx
Foods containing folate Pancreas
Foods containing carotenoids Mouth, pharynx, larynx, and lung
Foods containing beta-carotene Esophagus
Foods containing lycopene Prostate
Foods containing vitamin C Esophagus
Foods containing selenium Prostate
•，•錢
R«pm_d n pert by permM«on. taom World Cancer n___ch Fund and the Amencan ln«mu_ tor Cancer RMMrch. 2007 Food* and drink* In Food,
nutrition, physical «ctMfx and tf» p/^venbon of cancer. A global penpecBve (WMhngton. DC. American tnattule tor Cancer na，e_tf”. 78.
www.dKtandcani^rrepon.CMgi'doaffiioads/cttapaefS/chaptBf M.pdi
colonic cells. As well, fiber fermentation products women. Alcohol in small quantities does not appear
(e.g., butyrate) produced in the gut can help pro to prevent cancer as it docs cardicwascular disease?
mote healthy cellular growth. Furthermore, intakes The effect of alcohol intake on cancer prognosis has
of fiber and folate are correlated, and hence, the been studied in relation to breast cancer; however,
observed effects may actually be from fohte. the effect remain，uncertain. Alcohol intake has
not been associated with breast cancer recurrence
Red Meat and Processed or overall survival in most studies of women diag-
nosed with breast cancer?7
Meat Alcohol may increase cancer risk via mul
There is convincing evidence that consumption of tiple pathways?13 Some of its metabolites and by-
red meat and processed meat (ix., preserved by pnxiucts, for example, may be carcinogenic Alcohol
smoking curing, salting, or with preservatives 》 also acts as a solvent, which facilitates the entry of
increases the risk of colorectal cancer A 41 Very few other cancer-causing compounds (e.g., as found in
studies, however濟 have examined the effect of diet tobacco) into cells. Hence, for certain cancers, the
on colorectal cancer recurrence and survivorship. In combined cancer-causing effects of alcohol and
one follow-up study of patients with stage III colon tobacco are worse than they would be for either
cancer, postdiagnosis intake of a "Western diet* substance alone. Furthermore, alcohol may indi
(high intake of red and processed meats, sweets， rectly alter normal cell cydes, affect the metabolism
French fries, and refined grains) was associated of other carcinogens, increase circuiting hormone
with higher risks of recurrence and death, whereas levels, and reduce folate levels.
a "prudent die广 (fruits, vegetables, legumes, fish,
poultry, and whole grains) was not associated with
an increased risk.1】" Whether these findings are
Salt
attributable to meat intake specifically, however, Total salt intake and the intake of salted and salty
is unknown. foods are probably associated with stomach cancer,
Red and processed meats might increase cancer and intake of Cantonese-shrle salted fish appears
risk because potentially carcinogenic N-nitroso com to increase the risk of nasopharyngeal cancer?
pounds art： formed in the stomach and gut follow Salt intake could plausibly cause stomach cancer
ing their ingestion. Cooking at high temperatures by damaging the stomach lining, increasing the
produces potentially carcinogenic by-products, and formation of N-nitroso compounds, which are
the heme iron content of mcaU may also promote potentially carcino^mic, or interacting with other
DNA damage and cancer in the colon. Moreover, carcinogens. It is also hypothesized that salt intake
processed meats are high in salt, which also encour and Heliobacter pylori infection might act synergis
ages the formation of N-nitroso compound.' •’ In tically to increase risk.143 Salted fish may inervase
addition, higher meat consumption may coincide the risk of cancer of the nasopharynx because of its
with low intakes of fruits, vegetables, and fiber, N-nitrosamine content.5
which may decrease cancer risk.
Dietary Supplements
Alcohol !n their report on diet and cancvr prwentiem, the
There is now a wealth of convincing evidence' World Cancer Research Fund and the American
that total alcohol intake, irrespective of the source, Institute for Cancer Research5 do not recommend
increases the risk of cancent of the mouth, pharynx, dietary supplements for the purpose of preventing
larynx, esophagus, coIorectum (in men广 and breast cancer. Instead, they recommend that proper nutri
in both pre- and postmenopausal women.1’니'10 With tion be attained through the intake of foods alone.
respect to breast cancer, the increased risk from Although evidence suggests that some supple
alcohol appears to be the most elevated in women ment use may help prevent cancer, high doses
with low folate intake?41 It is less convincing, but can actually cause cancer in certain subgroups of
still probable, that alcohol assumption increases the population. For example, convincing evidence
the risk of liver cancer and of colorectal cancer in supports a causal role for hiî-dose beta-carotene
supplement use in lung cancer, depending on

smoking status and genetics.' The American Cancer Take-Home Message
Society similarly advises cancer survivors to avoid 심f Diet and cancer is a prolific
very high doses of vitamins, minerals, and other area of research, but stil.
dietary xuppkmcnts; they state that althcmgh low much uncertainty exists, par-
doses may be useful, they should only be taken with ticuUrly with regard to cancer
advice from a health care provider/2 recurrence and survival. A variety of plau
sible diet-related mechanisms have been
Recommendations for Diet proposed, and in the context of whole food
and Cancer consumption, these mechanisms are likely
intertwined People should consume a plant
The pool of scientific evidence on diet and cancer based. whole foods diet that is rich in fruits,
is already vast and continues to expand; however, vegetables, and whole grains tor the pre
much uncertainty remains. In the meantime, there vention of cancers and tor improved cancer
fore, it is recommended that the general population prognosis.
consume whole foods, follow a healthv dietary
pattern, and be mindful of total caloric intake and
body weight.13 More specific recommendations are
outlined in the sidebar Dietary Recommendations
for Preventing Cancer. If they can, and unless other
Summary (、
wise advised, cancer survivors should follow cancer A wealth of literature describes evidence relat
prevention recommendations for diet, weight, and ing cancer risk to body weight, physical activity,
physical activity? ' and various aspects of diet. Convincing evidence
Dietary Recommendations for Preventing Cancer

• Consume energy-dense foods sparingly.
• Avoid sugary drinks.
• Consume fast foods spanngly, if at aN^
• Eat at least five portions or servings (at least 14 oz or 400 g) of a variety of nonstarchy vegetables
and of fruits every day.
• Eat relatively unprocessed cereals (grains), pulses (legumes), or both, with every meal.
• Limit refined starchy foods. If you consume starchy roots or tubers as staples，you should also
make sure you consume sufficient nonstarchy vegetables, fruits, and pulses (legumes).
• If you eat red meat, consume less than 16 oz (500 g) a week; very little, if any, of that should be
processed.
• If you consume alcoholic drinks, imit consumption to no more than two drinks a day if you are a
man and one drink a day if you are a woman.
• Avoid salt-preserved, salted, or salty foods; preserve foods without using sail
• Limit your consumption of processed foods with added salt to ensure an intake of less than 6 g
(2.4 g sodium) a day.
• Do noteat motdy cereals (grains) or pulses (legumes)?
• Dietary supplements are not recommended for cancer prevention.
'CotMndng evidence M)ports a causal reiafeon between allaloxin exposure and fever cancer in humans? Aflaknon ts a potent
Irvor toxin and carcaiogen produced by certain molds or hogi that grow on gravis, tegumes. nuts, and seeds under warm, hunvd
corxMon*. OMptte «xi«*ng reguiatiors and control mMtums to prwent human analcuan exposum n developed comtnM.
exposure m rampant in dw«4op4ng countriM where control measures are not toastie or praatcal.'4*
Adapted from Wbrtd Cancer Research Fwd and the Amencan Instarte tor Cancer Reseaicfi 2007
Lifestyle Factors Associated With Cancer Incidence, Recurrence, and Survival
supports causal associations between overweight 3. Calle EE, Rodriguez C, Walker-Thurmond K. Thun
and obesity and five cancers; preventive roles for MJ. Chcrwcight obesity, and morUlity from cancer
in a pruspvctively studied cohort erf US. adults. N
physical activity in cancers of the colon, breast,
En^l J Med. 2003; 348:1625*1638.
and endometrium; and both helpful and harmful
4. McCkc DL. Body mass inck、and nwrUlity: Ameta-
effects from various aspects of diet on numerous
analyMs ba«ivd on perMxvIev el data from twenty-six
cancer sites. The overall evidence describing these observational studies. Ann EpidemtoL 2005; 15： ^-97.
effects in cancer survivors, however, is weak if not
5. World Cancer RcM?urch Fund and the American
lacking altogether. Consequently, international and Institute for Cancer Research. rFood, Nutrition,
US. recommendations for cancer survivors are to Physical Actiinty. and the Prrnnf名m ofCan公er: A Global
follow the advice given to the general population Perspective. Washington, DC: American Institute for
for cancer prevention, while accounting for the Cancvr Ri*s«arvh; 2007.»
risks associated with specific cancers and their 6. 1ARC Workii^ Gnxip, World Health OrganizeborL
treatments. In brief, these recommendations include Weight control and physical activity一 IACR hand-
maintaining a healthy body weight; exercising at bixtk for caitftr prevention. Vol. 6. Lyon, France:
IARCft«;z2002.
minimum 30 minutes per day, five days per week
7. Key T), Schatzkin A, Willett WC, Allen NE, Spencer
and at moderate intensity (but preferably more);
Travis RC. Diet, nutrition and the prevmtion of
and eating a whole foods diet that is rich in fruits, ^5nc»r. Public Health Nutr. 2004; 7:187-200.
vregetablesx and grains and low in fat and added
8. Renehan AG, Tyson M, Egger M, Heiler RF, Zwahlen
sugars, red and processed meats, salt, and alcohol. M. Body-ma»s index and incidence of cancer: A
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physical activity, and diet in relation to cancer obsenational studies. Lanett. 2008; 3/1: 569-578.
risk, many aspects of these associations remain 9 Renehan AG, SoerjomManun t, TS"son M, Egger M,
unclear. More research is needed to understand the Zwahkn M, Coebergh JW, Buchan 1. Incident cancer
biologic mechanisms explainii^ past findings and burden attributable to evoess body mass index in 30
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11. Pan SY, UesMeuies M. Energy intake, physical
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acti\ if\; energy balance, and cancer Epidemiologic
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evidence, it is ifCognizcd that other risk factors
나 Olsen CM, Given AC, Whiteman DC, Sadeghi S,
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CHAPTER 4
Benefits of Physical
Activity After a
Cancer Diagnosis
Kristin L. Campbell, BSc PT, PhD
following:
• Knowledge of physiologic outcomes that may be improved by exercise training among cancer
survivors.
• Knowledge ot symptoms and psychological attributes that may be unproved by exercise

training among cancer survivors.
• Knowledge of lymph, immunologic, cardiac, neurologk:. and hematologic systems as they

pertain to cancer-specific exercise issues.
• Knowledge of acute and chronic effects of exercise on temperature regulation and the adverse
thermoregulatory/vasomotor symptoms (e.g.. hot flashes) experienced by many cancer
survivors.
49
The understanding of the role of physical activity who have completed treatment (but may still be
after a cancer diagnosis has expanded gTeatly in the receiving hormonal treatment). In addition, the
past 20 years. Traditionally, during and following median age of cancer diagnosis is 65 to 69 years of
cancer treatment, people were told by health care age, requiring that fitness professionals have famil
providers and well-intentioned family members iarity working with older populations.
to rest and conserve energy. However, it is now Many cancer survivors will be deconditioned
understood that physical activity can hdp to allevi following surgery and cancer treatments. Fitness
ate many of the effects o( cancer treatment; there professionals should be familiar with working
fore, survivors should be encouraged to engage in with people with lower baseline exercise capacities.
physical activity, as able, both during and following Finally, the reseirch on the beneficial effect of physi
treatment? cal activity ixiearuxT survivors has focused on those
Initially, much of the research on the benefits undergoing treatment and f(섰lowing treatment for
of physical activity for survivors came from the earlier,tagp cancers. The role of physical activity
exercise psychology literature, with documented in suivivors with metastatic cancer or in the pallia
improvements in quality of life and feelings of well tive setting is beyond the scope of this chapter. The
being. The research has since expanded to include exercise center intake form in figure 4.1 is included
awareness that survivors can achieve the same as an example of pertinent client iniiwmation.
physiological benefits of physical activity as those
in the general population. However, cancer treat
ments, including surgery, chemotherapy^ radia*
tian, and hormonal therapies, do affect survivors' ，경象 Take-Home Message
physiological responses to physical artivity, and
서■障 Although cancer survivors will
, not expect fitness professionals
also cause side effects that are unique to this popula
tion. Fitness professionals need to understand these
to be experts on cancer treat*
unique factors when prescribing physical activity
meat, such professionals will
and monitoring the response to physical activity of
need to understand the basic aspects of can
cer treatment, which are commonly surgery,
cancer survivors^
chemotherapy, and radiation. Those working
The evidence supporting the benefits of physi
with a particular cancer group should get to
cal activity following a cancer diagnosis comes
predominantly from studies in female breast cancer
know some of the specific issues and com
survivors, both during and following trratnumt (che-
mon treatments their clients face.
motherapy, radiation, or both), and prostate cancer
survivon, with limited research regarding cokvi
and gynecological cancer survivors. The response to
physical activity of other survivor groups may differ Physiological Effects of
depending on the cancer site and the associated
treatment approach. The summary of the evidence
Exercise Training
used to develop the consensus guidelines in the 2010 The health-related physical fitness components
M American College of Sports Medicine Round table are cardiorespiratory fitness, muscular endurance,
on Exercise Guidelines for Cancer Survivors* is muscular strength, flexibility, and body composi
divided by cancer type (see table 4.1).1 tion? Improving these components is a goal of
Fitness professionals should seek specific infor exercise interventions. When developing an exercise
mation on the type of treatments and associated side prescription, fitness professionals should take into
effects when working with particular cancer groups. account whether the person is still receiving treat
Furthermore, the timing related to treatment(s) may ment or has completed treatment. Exercise has been
change the types of exercise that clients can engage shown to result in improvements or maintenance
in and their response to exercise. The goals of a of physiological and psychological factors during
physical activity intervention for people receiving treatments such as chemotherapy and radiation.
treatment (Le., surgery, chemotherapy, radiation, or Greater improvements, however, are generally seen
a combination of these) differ from those of people when exercise is undertaken following comple-
Benefits of Physical Activity After a Cancer Diagnosis 51
TABLE 4.1 Summary of the Evidence of the Safety and Efficacy of Exercise Training
by Cancer Site
Cancer site
Breast Breast Hematologic Hematologic
(during (following cancer cancer
treatment) treatment) Prostate Colon Gynecological (noHSCT) (HSCT)
Safety A A A - A
Aerobic A A A - . A C
fitness
Muscular A A A C
sirengin
Flexibility - A - - - -
Body B B B — —
composition
Quality B B B - - C
of life
Fatigue B B A - B c
어her B B
psychosocial (anxiety) (depression)
factors B
(anxiety)
B
(body image)
어her A B
(physical (physical
function) function)
C
(pain)
(yᄍ
A
(salety for
/ lymphedema
onset or
worsening)
Evaluation oi evidanc* t_Md on Vw caiftgones outknod by the Nateonai HMft. Umg and Blood imtNuto/* A (overwtwinvng data from randomoMi controaed
inats), B (tow randomized controled tnals eousi at they are small and the results a歸 nconaslenf). C (resUte stem from uncontrolled, nonrandomzed. and/or
otiaarvatKx낸 sludbe이. - (not suffoent evidence^
MSCT ■ h_n_topo__c iMm tovwptar讀abort

Adapted. t>> permiBaton. from K.H. Scfmttz at at, 2010, *Amencan Cotege of Sports Meocine rcxndtat)ie on eie<cise giMMnes tor cancer survMn.*
Medtane and Science n Sports and Exercise 42 (7): 1409-1
tion of active treatment4 This should not dissuade studies in breast (during and followii^ cancer treat
people from starting or maintaining an exercise pro ment) and prostate cancer survivors.1 However,
gram during treatment, but clear expectations about in general, this effect may be stronger after treat-
the anticipated responses will help to align the goals ment.“ Cardiorespiratory fitness has been mea
of both the survivor and the fitness professional. sured as peak oxygm consumption (VOjpeak) or by
using functional tests, such as the 6- or 12-minute
Cardiorespiratory Fitness walk test, in breast cancer,4 7 prostate cancer," hema-
There is consistent evidence that aerobic exercise tok>gic cancers/ and mixed cancer survivors?
training improves cardiorespiratory fitness in The exercise prescriptions in these studies have
cancer survivors, with the strongest evidence from followed basic exercise physiology principles and
Figure 4.1 Exercise Center Intake Form

Name: Date (DO/MM/YR):
Date of birth (DD/MM/YR): Age:
Emergency Contact
Name: Relationship:
Home phone number: Cefl phone number:
Medical History―Cancer
1. What was the date of your cancer diagnosis (MM/YR)?
2. What type of cancer were you diagnosed with (e.g.. breast, lung)? 외^ _ _____________________
3. What stage was your cancer? 0 I II III IV Undetermined Don't know
4. If applicable, which side of the body was your cancer on? jC Left Right Both N/A
5. What types of cancer treatments have you received or wiN you receive in the future?
Surgery No Current Completed: dale (MM/YR): /

Future/pianned: date (MM/YR): •
Chemotherapy No Current Completed date (MM/YRk /

Future/planned: date (MM/YR): /
Radiation No Current Completed: date (MM/YR): /

Future/planned: date (MM/YR): /
Type of surgery (if known):
6. Please provide any other comments you have about your cancer or cancer treatment (il applicable)：
Medical History—General
7 Do you have any other current medical conditions? (Please check all that apply.)
지그 Hypertension (high blood pressure)

Diabetes
Z High cholesterol
Arthritis or joint pain
Other (specify):
8. Please list your current medications and supplements, including any medications that are part of your
cancer treatment, such as hormone therapy. (Please provide the names as best as you can remember
them and what they are for.)
52
9. Please list any injuries you have had (past or present) and how they may limit your physical activity (if
applicable).
For Staff Use: Medical Notes
[ Lose Information
General weight
10. DWhat is (specify):
Other your main goal related to _starting an exercise program?
11. DoPhysical fitnessany barriers to starting an exercise program?
you anticipate
Achieve a particular goal (i.e., start a new activity, participate in an event) (specify):
Lack of time
C Lack of enjoyment from exercise
C Lack of self-discipline
Lack of equipment
C Fatigue or feeling unwell
c Weather
Finndal
r. Other responsibililies (e g., family, job. volunteer position)
7? Other (specify): ________________________________________________
12. Do you have any specific cancer-reiated ooncerns about exercise?

z Type of exercise that is safe during or following cancer treatment
C Risk of infection at the fitness center or public facilities
C Risk of developing lymphedema
[ Knowledge of fitness center staff related to working with cancer survivors
Other (specify):
《continued}
Exercise Center Intake Form (continued)
13. What types of physical activities do you currently do or have done in the past?
For Staff Use: General Notes
FromACSM. 2012. ACSM"9 guui9 to aurytvonf^p (Ctwmpegn. t.; Human Kirwtocs>. Dvwtoped by S N_l. A. Kif1tf*nandK C«mpMI
have UM*d a variety of aerobic exercise prescrip Frequency and Intensity

tions, as follows:
Although the wide range of reported exercise pre
scriptions used in the research to date, as well as
• Frequency： Two to five days per week
the diversity of cancer types and related treatments,
• Intensity: 50 to 75% of measured or predicted
has made it difficult to develop specific exercise
maximum heart rate
guidelines for each cancer type or treatment, the
• Type: Walking primarily, along with other
2010 "American College of Sports Medicine Round-
aerobic activities
table on Exercise Guidelines for Cancer Survivors"
• Time: 10 to 60 minutes per session provides consensus guidelines.1 These guidelines
• Duration of program: 6 to 26 weeks for cancer survivors are consistent with the 2008
U.S. Department of Health and Human Services

(U.S. DHHS) * Physical Activity Guidelines for
，경夢 Take-Home Message
Americans.Cancer survivois are encouraged to
십f During treatment, cancer sup
meet the US. DHHS guidelines for aerobic activ
vivors are encouraged to con
ity of 150 minutes per week of nuxlcrate-intensity
tinue with their usual physical
exercise or 75 minutes of vigorous-intensity exer
activity, but may need to reduce
cise (or an equivalent combination). However, if
the duration or intensity, or both, depend
cancer survivors are unable to meet these reccxn-
ing on how they are feeling. A good rule of
mendations as a result of their health status, the
thumb may be that if a client is used to run
U.S. DHHS and the ACSM roundtable guidelines
ning marathons, a good goal foe exercise
recommend that they "should be as active as their
during treatment may be io aim tor running 3
abilities and conditions allow" and, overall, "avoid
to 6 miles (5 to 10 km).
inactivity,"*
Timing
This blunting* of the negative effects of adju
The timing of the intervention either during or fol
vant cancer treatment (i.ev chemotherapy, radiation,
lowing cancer treatment may affect the degree of
or both) as a result of aerobic exercise (i.e., no or
cardiorespiratory fitness improvement The current
small improvement in the intervCTition group and a
research suggests that during treatment aerobic
decline in the cofltrol group) has also been observed
exercise helps to maintain cardiorespiratory fitness
in other studies that measured cardiorespiratory
or results in small improvements compared to a
fitness using the 12-minute walking test, with
decline in fitness seen in people in control groups
improvements ranging from +38 to +328 meters in
who are not exercising.
the aerobic exerdse groups, compared to a decline
In a recent randomized controlled trial of aerobic
or smaller increase in the usual care groups (-91
exercise in breast cancer survivors during chemo
to +42 m》.1시" However, this respimse may differ
therapy treatment (three days per week, 45 minutes
according to the type of treatment, particularly
per sessions at 60 to 80% of VOjnax; median dura-
treatment that includes chemothempy.
ticwi of the intervention was 17 weeks), those in the
In one randomized controlled trial that enrolled
aerobic exercise groups had no change in cardiore breast cancer survivors in an aerobic exercise
spiratory fitness compared to a decline in VO.max of
intervention at the start of treatment (with or without
approximately 1.5 ml/kg/min, or 6%, seen in the
chemotherapy), predict*신 VO,max was relatively
control group.11 In a randomized controlled trial of
unchanged in women receiving chemotherapy,
aerobic exercise in breast cancer survivors under whereas there was an improvement in those not
going radiation treatment (thrre to five days per
receiving chewcnherapy (1 and 3 ml/kg/min in the
week, 20 to 45 minutes per session, 50 to 70% of self-directed and supervised interventions groups,
maximum heart rate for seven weeks), the aerobic respectively). Furthermore, emerging evidence
exercise group reported a 6% increase (32 ml/kg/ in îxed cancer survivors35 and those with lym
min) in VOjnax versus a 5% decrease (-0.6 ml/kg/ phoma21 shows that highly structured aerobic inter
min) in the stretching control group.12 ventions that include higher*intensity intervals am
Similar results have occurred in prostate cancer be safe for people undergoing chemotherapy and
survivors receiving radiotherapy with or without may result in greater increases in cardiorespiratory
androgpn deprivation therapy (ADT), with a decline fitness~namely 10% tn 9 weeks in the mixed cancer
in VO,max of -1.4 ml/kg/min (-5%) in the usual survivors, and an increase of 4 to 5 ml/kg/min in
care group compared to maintenance in the exercise 12 weeks in the lymphoma survivors.
groups (+0.14 ml/kg/min, or 05%, in the resistance The observed decline in cardiorespiratory fitness
group and +0.04 ml/kg/min, or 0.1%, in the aerobic with cancer treatment has been attributed to factors
group).0 The aerobic exercise intervention was three such as reduced levels of usual physical activity,
day per week, 15 to 45 minutes per session, at 50 to anemia, tachycardia, dehydration, and cardiac dys
75% of V O，max for 24 weeks. function. Fitness professionals may find the Exercise
and Energyr Weekly Log (figure 4.2) helpful, espe in approaches to exercise prescription that have
cially when working with clients who are receiving been used and the varied results of the intrrven-
cancer treatment. This tool allows clients to track tions. The overall safety of exercise for cancer survi-
their level of fatigue over time, as well as during vors has now been established, as noted in the 2010
exercise sessions. The fitness profetusicmal can use ACSM roundtable guidelines? The research focus
this information to alter the exercise prescription. should now move toward exercise prescriptims that
are specifically designed to elicit a training response
and that rvport adherence to the intervention that
includes information on the prescribed intensity
Take-Home Message or duration of exercise rather than documenting
A client still on active treatment attendance alone (i.eM fre^Bency).The exercise
may have reduced tolerance for program intensity should be great enough to safely
exercise on specific days (e.g., stimulate improvements in cardiorespiratory fit
the day of treatment or the days ness and functional status. Baseline assessments of
immediately following a treatment session). cardiorespiratoty fitness can facilitate development
Exercise prescription may need to be tempo* of the mast appropriate and effective exercise pre
ranly modified on these days. It is also worth scription fur 續drvivors. The 2010 ACSM roundtable
remembering that as treatments progress, guidelines provide information on specific preex
exercise tolerance may decrease as a result ercise medical assessments and exercise testing for
of the cumulative effects of the treatment oincer survivors and overall support the safety of
aerobic exercise for cancer survivors.1
In summary, physical activity levels, Along with
In contrast, more consistent improvements in cardiorespiratory fitness and functional capacity
aerobic fitness have been noted in interventions that levels, tend to decrease with cancer treatment,
take place following cancer treatment. Randomized especially chemotherapy. The overall goal of exer
controlled trials in cancer survivors following treat cise during treatment may be to maintain cardio
ment have revealed aerobic fitness improvements respiratory fitness or functional capacity, rather
(measured as VO2max) ranging fr<nn 2.2 to 7.3 ml/ than improve it. The period following completion
kg/min in the exercise group (7 to 19%), whereas of cancer treatment may be a better time to focus
controls showed little change or declines of up to on improving cardiorespiratory fitness. Specific
1.7 ml/kg/min, or 6%.°^ Similarly, improvements rveommendatierm for dewloping an appmpriatc
have also been noted during the 6-minute walk
test, the 1-mile or 2-ldlometer walk test, and cyde
ergixneter tests.
Take-Home Message
Specificity of Training Following cancer treatment,
The method of prescription used in research stud* some survivors may want to get
ies of aerobic exercise interventions in cancer popu back to their prediagnosis phys
lations htR varied substantially - Training principles
ical activities quickly. After treat
such as specificity, overload, progression, and ment, which usually lasts 6 to 12 months, re
initial fitness level to guide the prescription have gaining fitness takes time. To avokj feelings
not been applied universally. Some interventions o< frustration on the part of client or excessive
have employed home4)ased walking programs fatigue tor several days following an exercise
with targeted frequency (i.e‘, days per week) and sessk)n. the fitness professional should start
duration (i^., minutes per week) goals/' whereas the client s exercise program slowly (startrig
others have been individualized based on maxi witti 10 to 15 minutes per session) and aim
mal aerobic fitness testing to determine specific for consistency (three to five days per week)
workloads.3 while monitoring the clients response ar、d
The earliest aerobic research for cancer survivors altering the prescription as needed.
focused on safety. This may explain the >vide variety
Figure 4.2 Exercise and Energy Weekly Log
Name: Date (DD/MM-DD/MM^YR):
For each section, please check the appropriate box daily.
Number of hours
of sleep last night. Monday Tuesday Wednesday Thursday Friday Saturday Sunday
12+
10-11
8-9
G-7
4-5
<4
How would you describe the quality of sleep you experienced last night?
Very deep
Normal
Restless
Bad with breaks
J
I did not sleep
Did you take any sort of sleeping aid?
Yies/No
Name
How would you describe the severity of the fatigue you are experiencing today? (0 = None; 10 = Severe)
0-10 一一거지
How would you describe your interest level in physical activity today?
Very high
Good
Low
No interest
Comments:
(continued)
Exercise and Energy Weekly Log (continued》
Home Exercise Log

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Activity • Walking • Walking • Walking • Walking • Walking • Walking • Walking
• Bicycling • Bicycling • Bicycling • Bicycling • Bicycling • Bicycling • Bicycling
• Other: • Other: • Other: • Other: •Other: • Other: •Other:
Time (minutes)
Average heart
rate
RPE (6-20)
Comments
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Activity •Walking • Walking • Walking • Walking •Walking • Walking • Walking
• Bicycling • Bicycling • Bicycling • Bicycling • Bicycling • Bicycling • Bicycling
• Other: • Other • Other: • Other: • Other: • Other: •Other:
Time (minutes)
Average heart
rate
RPE (6-20)
Comments
From ACSM. 2012, ACSUa guide to aas^se ana cttncw wmvonlup (Champaign. IL. Human KoMca). Adapted tram T Bompa, 2000. P9noda，_on Mining
Theory and methodology: and Piper Fatigue Scale.
58
exercise prescription are found in chapter 6. How- surgery and treatment Results from recent research
ever, further research is needed to establish the most have suggrsted that pr<»grM»ive resistance training
effective exercise methods for cancer survivors. improves muscular strength, muscular endurance,
and functional ability, without increasing the risk
Muscular Strength and of developing upper«xtremity lymphcdemaa,* or

exacerbatini； preexisting lymphedema.w
Endurance Schmitz and colleagues은 studied breast cancer
Resistance exercise training has been effective in survivg，，with preexisting lymphedema. The exer
improving muscular strength and endurance in cise group had an increase in strength, measured
cancer survivors,a with the majority of research as 1 RM, of 29.4% for the bench press (versus 4.1%
being in those with breast cancer/* prostate in controls) and 32.5% for the leg press《versus
cancer,30 and head and neck cancer.31-32 Muscu 7.6% in controls). The exercise group reported a
lar strength has been measured as 1-repetition significant improvement in lymphedema symp
maximum (1RM) or 6- to 7-repetition maximum toms. Also, exacerbations of lymphedema were
to estimate 1RM. Muscular endurance has been nominal in the exercise group, which also had fewer
measured as the number of repetitions of a certain exacerbations compared to the control group. The
weight in a set time. Assessing baseline muscular key message stressed in this study was adhering to
strength and endurance is important for developing proper form and progressing the exercises slowly.
the most appropriate and effectire prescription for
To achieve this, the study included supervision
cancer survivors. by trained instructors for the first 13 weeks. Also,
Research studies with cancer survivors have used
the intensity started low and progressed slowly
a variety of resistance prescriptions,〉as follows:
by the smallest iiwrement to reduce the risks of
• Frequency: One to five sessions per week worsening lymphedema. In addition, participants
(primarily two or three) wore compression sleeves during their resistance
• Number of exercises: Varied numbers involv exorci，P sessions, and symptoms of worsening
ing large muscle groups (primarily five to lymphedema (i.e., swelling, feelings of heaviness)
nine) were closely monitored.
• Sets： One to three sets Resistance training has also been encouraged
for prostate cancer survivors undergoing androgen
• Repetitions: 8 to 12 reps
deprivation therapy, which lowers testosterone
• Intensity: 25 to 85% of 1RM
levels. The treatment-associated reduction in muscle
• Duration of program: 3 to 52 weeks
mass and muscle strength can compromise physi
The 2010 ACSM roundtable guidelines for resis

cal function, particularly in older men.30* In a
tance training exercise for cancer survivors are also study that compared a 12-week resistance training
consistent with the 2008 U.S. DHHS "Physical Activ program and a usual care group during ADT treat
ity Guidelines for Americans."1 Cancer survivors ment, the exercise group had a significant increase
are encouraged to meet the US. DHHS guidelines of in upper- and lower-body muscular strength (1RM)
two or three weekly sessions that include exercises and endurance (number of repetitions of 70%
for the major muscle groups,10 as able. 1RM) compared to the control group, * with an
Strong evidence of the benefit of resistance train 11% improvement in 1RM chest press (versus 1%
ing has been reported in breast cancer and prostate in controls) and 37% improvement in the 1RM leg
survivors during and following cancer treatment.1 press (versus 7% in controls).
The role of resistance training following surgery Resistance training has also been studied in head
for breast cancer has been controversial; tradition and neck cancer survivors. Resistance training in
ally, practitioners have advised people not to lift this population may be particularly important
more than 10 pounds (45 kg) and to limit repetitive because of the associated shoulder dysfunction,
upper-extremity activities.35-u These limitations vvhkh is a well -recognized complication of the neck
were aimed at reducing the risk of developing di汝tec tian surgeries cummcmly uited. The shoulder
upper-extremity lymphedema, swelling that can dysfunction is due to damage to or resection of the
affect the arm and trunk following breast cancer spinal accessory nerves and surrounding muscles,
such as the trapezius muscle. A small randomized The 1-repetition maximum (1RM) test has been
controlled trial compared a 12-week standard care employed during recent exercise studies with breast,
program that included range-of-motion, stretch prostate, and head and neck cancer survivors to
ing, and shoulder-strengthening exercises with determine the appropriate exercise prescription for
elastic resistance bands with a 12-weck progressive program.11 w * This informatiem has then bt*m used
resistance program based on individual baseline to develop an exercise prescription in a variety of
strength testing. Both groups improved muscular ways. The initial intensity for head and neck cancer
strength and endurance, but the individualized, survivors was set at 25 to 30% of 1RM and pro
progressive program resulted in greater impren e- gressed to 60 to 70°o of 1RM. The protocol induded
ments in 1RM for the seated row (37% versus 15% both double- and single-limb (arm) exercises,
in the standard care group) and the chest press (45% because strength was di^proportionally reduced
versus 24% in the standard care group).30 on the treatment side as a result of surgery or radia
tion.12 This study included both men and women,
Timing making an individualized approach even more
The majority of resistance training programs for important than in studies of a single sex. For breast
people with cancer have been undertaken following cancer sumvors with or without lymphedema, the
cancer treatment and have reported benefits.2* How- goal of the program by Schmitz and colleagues15
ever, research on the benefits of resistance training was to progress slowly to avoid acute injury to the
during chemotherapy treatment is limited. During arm. Dannge to the arm has been suggested as a risk
chemotherapy, an improvement in strength was factor for lymphedema (see chapter 6). The authors
reported in breast cancer survivors who were ran did not set an upper limit for resistance.
domized to a resistance exercise program compared Supervision is another key feature in achieving
to those randomized to an aerobic exercise program specificity of resistance training. Supervision ini
or control group (the only group to maintain their tially or for the entire study can ensure that clients
usual lifestyle)." In addition, the resistance in use proper form and an appropriate progression.
this study also had a better chemotherapy comple Home-based programs are more difficult to moni
tion rate than the aerobic exercise or control group tor for proper form or appropriate progression of
did. A better chemotherapy completion rate means reUstance, which may limit clients' gains in strength
that people were more likely to receive their pre and endurance.
scribed chemotherapy dose on schedule, instead of Finally, adherence and compliance to the pre
experiencing the delays commonly seen with chemo- scribed intensity and progression have not been
ther^y- A better chemotherapy completion rate is an well documented in the literature, which limits the
outcome that may be of particular interest to the clini ability to determine the overall expected effect of
cal oncology communHy (i.e., cwxologists) because resistance programs for cancer survivors. Further
delivery of the prescribed chemotherapy dose is research is needed to continue the development
linked to improved clinical outcomes. Improve of feasible and effective resistance programs for
ments in upper- and knver-bcxiy strength were also cancer survivors.
noted in prostate cancer survivors who took part in
a resistance program during radiation therapynand
during androgen deprivation therapy.*
Flexibility
A reduction in range of motion following surgery for
Specificity of Training cancer is common, and treatment to improve range
As with aerobic interventions, issues with specificity of motion is usually done by physical therapists.
also exist for resistance interventions. Baseline testing However, the role flexibility plays in recovery from
has not been used universally. A generic approach cancer treatments is an important issue. Currently,
to prescribing resistance exercise that does not take there is little research on the effect of exercise inter
baseline strength into account may result in an exer ventions on flexibility in cancer survivors, but the
cise prescription that is too easy (and therefore results evidence that is avaihble reports an improvement in
in less improvement》or too hard (limiting improve upper- and lower-body flexibility with exercise inter
ment and possibility increasing the risk of injury). ventions in cancer survivors following treatment?
Benefits of Physical Activity After a Cancer Diagnosis
In addition, recent research has examined the role Six intervention studies of prostate cancer survi
of yoga as part of the physical activity prescription vors have shown an improvement in weight control
for survivors, especially breast cancer survivors.* and the prevention of increased fat mass, along with
The majority of yoga studies have focused on a maintenance or increase of lean mass/3 M *■45-17
quality of life, fatigue, and psychological benefits. whereas ftve other intervention studies shcmred no
Improvements, however, in sit-and-reach distances benefit.*A three-arm randomized controlled
have been reported in a pilot study of yoga in breast trial compared the effects of a 24-week inten ention
cancer surxrivors following active treatment.v Oxw (with a usual care group, resistance exercise group,
all, this component of fitness has not been a focus of and aerobic exercise group) in men with prostate
exercise intervention research in cancer survivors cancer, the majority of tvhom were receiving andro
to date. gen deprivation therapy. In addition to improving
strength, the resistance exercise intervention also
prevented an increase in body Fat (measured by dual
Body Composition energy X-ray absorptiometry) seen in the other two
The issues around body composition differ by intervention groups. Lean mass was not measured.13
cancer type and type of cancer treatment. Weight This Suggests that resistance training may be of
gain is commonly seen after a diagnosis of breast great benefit to men receiving androgen deprivation
cancer, particularly with chemotherapy and radia therapy for prostate cancer treatment to prevent or
tion treatment.4* The cause of this weight gain minimize the commonly observed body composition
appears to be a combination of a reduction in usua! changes associated with such treatment.
physical activity level, acceleraticxi into menopause Finally, weight loss and cachexia (muscle wast
of previously premenopausal women, and a pos ing) may be an issue for survK이■» of other cancers,
sible side effect of hormonal therapiti< such as such as lung cancer. Beneficial effects of resistance
aromatase inhibitors.41 ° Weight loss intervention training alone or in combination with nutritional
studies in breast cancer survivors following treat support to reduce muscle wasting have been sug
ment have revealed some short-term success using gested, but currently little research has been done
combinations of indhidua! ot group dietitian-led on cancer survivors with cachexia.52,®
counseling, and commercially available programs,
with or without the inclusion of exercise. Exercise
interventions in breast cancer survivors, without
a dietary component or designed goal of weight
Psychological Benefits
loss, have resulted in weight maintenance but not of Exercise Training
weight loss or reduction in BMI.* More information
The most commonly reported psychological
is needed to determine the most effective method
domains in research of physical activity in cancer
for weight loss for this population because of the
survivors are quality of life and fatigue. Let's take
unique factors that contribute to weight gain.
a doser look at those two areas.
Furthermore, the goal of achieving a healthy body
weight is commonly delayed until the completion
of adjuvant treatment. Quality of Life
Significant increases in fat mass and decreases Improvements in quality of life have been reported
in lean muscle mass have been consistently noted with exercise interventions in breast cancer sur
in prospective studies of men receiving androgen vivors both during and following treatment/
deprivation therapy, with greater changes seen with measured by the general version of the function
longer durations of androgen deprivation therapy“ assessment of cancer therapy scale (FACT-G) and
Observed decreases in strength and associated func the breast cancer-specific scale (FACT-B). However,
tion, such as 4-meter walk velocity, have implica in other reviews of the literature, improvements
tions for overall physical function and a concomitant in quality of life are noted to be stronger or pres
increase in fat mass that may put these people at ent only with interventions undertaken follcmung
higher risk for developing metabolic syndrome and active cancer treatment? During treatment, espe
cardiovascular disease.** cially chemotherapy, quality of life scores appear to
vary considerably among individuals, which may controlled trial), but no effect was seen in a low-
account for the lack in observed imprwement in intensity h(Hne-bas<rd randomized controlled trial.1
quality of life with exercise interventions compared The etiology of cancer-related fatigue is not fully
to interventions undertaken following treatment.11 understood. Anemia and other factors should be
However, improvements in quality of life hax e medically managed. Hourever, beyond these fac
been noted in prostate cancer survivors participat tors, low levels of energy can lead to lower levels of
ing in exercise interventions during treatment.’ physical activity, resulting in deconditioning. This
Resistance training mitigated the decline in qual then becomes a vicious cycle. The goal of physical
ity of life, compared to the usual lifestyle control activity interventions in relation to fatigue is to
group, in two recent randomized controlled trials maintain or improve physical function, when pos
in men receiving radiation with or without ADT'or sible, and to limit the* jssctciated deconditioning.
ADT alone38 for prostate cancer. In prostate cancer, Physical activity prescriptions for those with
quality of life has been strongly linked to physical significant fatigue may require a number of modi
function. Resistance training may help to maintain fications, including the following:
muscle mass and preserve physical function.37
• Slower progression, breaking physical activity
In observational studies, positive associations
into several short bouts throughout the day
between physical activity and quality of life have
also been noted in other cancer survivor groups—
• Engaging in physical activity at times of the
day when the person has more energy
namely, multiple myeloma; brain, ova nan, endo-
metrLib bladder, colorectal, and lung cancer; and • Careful monitoring of fatigue levels over time
non-Hodgkin’s lymphoma，However, randomized with adjustment to the prescription if fatigue
is worsening rather than improving
controlled trials are needed in the곳 diverse popula
tions to better understand the link between physical
activity and improved quality* of life. Other Psychbsocial Factors
Less evidence is available regarding the effect of
Fatigue physical activity on other psychological factors,
Fatigue is a common side effect of cancer treat such as anxiety, depression, self-esteem, happiness,
ment that can linger following the completion of and body image- Some improvements have bet?n
treatment. Decreased fatigue has been noted with noted; however, the evidence from randomized
exercise in cancer survivors/ and breast cancer controlled trials and controlled clinical trials is weak
survivors, specifically? However, these effects (for interventions both during and following active
appear to be stronger with interventions under treatment).®
taken following treatment,’Of seven randomized In a randomized controlled trial (which was the
controlled trials of exercise interventions aimed first to focus on adults with lymphoma), a 12-week
at decreasing fatigue during chemotherapy, four aerobic exercise intervention resulted in improved
rejxirted a significant effect, and three, including quality of life, decreased fatigue, increased feelings
the largest of these studies, showed no effect? In of happiness, and decreased feelings of depression,
exercise interventions that have assessed fatigue compared to the usual care control group. These
in breast cancer survivors following treatment, of improvements were maintained at six months post-
the nine randomized controlled trials, four reported intervention J1 Furthermore, these improvements
decreased fatigue, four reported no effect on fatigue, were similar in patients receiving chemotherapy
and one reported worsening fatigue.1 and those who had completed active treatment. In
In contrast, both resistance training and aerobic a three-ann randomized controlled trial in breast
exercise have been shown to mitigate the increase cancer survivors during chemotherapy, improve-
in fatigue observed in prostate cancer survivors. A ments in self-esteem were noted in both the aerobic
reduction in fatigue has been reported in exercise exercise intervention group versus control and in
trials in prostate cancer survivors undergoing the resistance exercise intervention group versus
androgen deprivation therapy (two randomized control.” This study also found that improvements
controlled trials), radiation therapy (one random in psychosocial factors may be associated with exer
ized controlled trial), or both (one randomized cise preference. Only the people who reported that
they preferred resistance training before random- groin, or leg can cause lower-extremity lymph
izahon and then were randomized to the resistance edema, and lymphedema can be found in the face
group had an improvement in quality of life. More and neck following head and neck cancer surgpry.
research into the effect of exercise preferences is Lymph is propelled by the rhythmic contrac
needed. tion of smooth muscle in the walls of the larger
In general, physical activity may be valuable in lymph vessels. The system also depends on the
attenuating the decline in quality of life seen with •auxiliary pumps,* such as skeletal muscle con
cancer treatment, and greater improvements may traction and breathing, to enhance flow, both of
result from exercise interventions undertaken fol Miich increase with physical activity. Therefore,
lowing treatment. Some improvements in other exercise is thought to assist lymphatic flow. The
psychosocial factors have been noted but not uni skeletal muscle acts as a pump, and may improve
versally. Imprcn ements may differ among patient lymphatic function in women with upper-extremity
populations, treatment timing, the measurement hnnphedeina. Uppeiêxtremity activity has been
t<x)l(s) u»ed, and other factors. shown to increase lymph flow in healthy controls,
women with breast cancer, and women with breast
cancer-rclatrd lymphedema.u * Regular physical
activity (resistance, aerobic, or both) may help the
、广• Take-Home Message lymph system to better handle the stresses of activi
Cancer survivors may experi ties of daily living and bouts of activity, although
ence depression or be under
the mechanism is unclear.3、* Lane and colleagues'*
significant stress. When pre
suggest that regular physical activity may result in
scribing an exercise program,
the development of new lymphatic vessels that help
fitness professionals may need to erx»ur-
to drain lymph fluid in the aim, but more research
age clients or make themselves more acces-
in this area is needed.
stMe to clients as they begin the program
In breast cancer survivors, seven randomized
A lollow-up phone call, for example, to a cli
controlled trials of upper-body aerobic exercise or
ent who misses an exercise session may be
resistance exercise have reported that the interven-
warranted.
tion did not contribute to the onset or worsening
of lymphedema.1 The largest of these randomized
controlled trials tested the safety of weightlifting
Cancer-Specific Exercise in breast cancer survivors with lymphedema. The

exercise group experienced fewer lymphedema
Issues by Bodyjystem flares or exacerbations (i.e., 14% compared to 29%

in the control group). Those in the control group
The effect of cancer treatments on various body also required more medical treatment for these
systems is^vell documented (see chapter 2). These exacerbations (195 treatments versus 77 in the
effects may influence how survivors respond to exercise group).*
exercise and what types of exercise may be appro* The use of compression sleeves during exerdse
to prevent the development of upper-extremity
lymphedema has been suggested. Although no
research supports a benefit to this, using a compres
Lymphatic System sion sleeve may encourage breast cancer survivors
The lymphatic system can be disrupted by lymph who are concerned about the possible development
node dissection surgery or radiation therapy. The of lymphedema to participate in exercise. In women
result of disrupting the lymph nodes is improper with preexisting lymphedema, the use of a com
clearance of lymph fluid, which can cause swelling pression sleeve during physical activity has been
of the affected area. Upper-extremity and upper advocated.* In a small pilot study that examined
trunk lymphedema foUawing brvast cancer surgrry upper-extremity limb volume after a short bout of
is the most well-known site of lymphedema, but upper-extremi ty activity, those with lymphedema
surgpry to the abdomen (e.g” for ovarian cancer). who wore a compression sleeve on the affected
arm had a smaller increase in limb volume in their cancer survivors following treatment. One showed
affected limb than in their unaffected limb. This no difference in the concentration of circulating
suggested that the skeve attenuated the normal lymphocytes or natural killer (NK) cell cytotoxic
increase in limb volume that exxurs with exercise. activity following an eight-week mixed aerobic
This might help to aUeviate stress on the lymph and resistance exercise intervention,1 whereas the
system in the affected limb.* More research on the other reported a significant improvement in NK cell
role of compressions sleeves during physical activ activity follcnving a 15-week aerobic intervention，2
ity is needed. Immune function is an especially important issue
Much less is known about the effects of exercise for people receiving high-dose chemotherapy and
on lower-extremity or facial lymphedema, and to hematopoietic ftum cell transplantation (HSCT) as
date, there is no evidence that aerobic or rcsinUnce part of cancer treatment. Early evidence frwn a ruin-
exercise reduces the risk of lymphedema or exacer randomized controlled trial suggests that a mixed
bates existing h^phedema in these areas. A better aerobic and resistance exercise program for three
understanding of the role of exercise and lower- monthb following transplantation did not facilitate
extremity lymphedema may be especially relevant faster recovery of measured immune parameters,
for gynecological cancer survivors and others who but neitfier did it hinder it compared to a non ran
have had lymph nodes removed or radiation to the domized control group?1 When randomized con-
lymph nodes in the groin.1 troUed trials and other study designs are included,
the overall results have been mixed with either no
change in immune function or improvements in
some measures of immune function (e.g., natural kill
Take-Home Message cell cytolytic activity, monocyte function, proportion
Many breast cancer survivors of circulating granulocytes, and duration of neu
worry about developing lymph tropenia) with aerobic or resistance training either
edema. Fitness professionals during or following treatment? 7 However, the
should check in with their cli maprity of interventions have focused on mexierate-
ents about any new symptoms of heaviness, intensity exercise. Therefore, little research exists on
pain, or swelling in the arm or the side of the effect of higher volume and intensity of activity
surgery. If new symptoms develop, clients in cancer survivors, both of which have been linked
should check in with a lymphedema special to immunosuppression in athletes.
ist or physician prior lo continuing resistance
training.
겨당 Take-Home Message
십y Cancer survivors, especially
Immune System * during treatment, are strongly
Immune* suppression is common with cancer treat advised to avoid situations in
ment, espedaUy* chemotherapy. Some are concerned which they may be at risk of in
that exercise, especially higher-intensity exercise, fection. Fitness professionals should ensure
could exacerbate this immunosuppression, and that the exercise space is clean and that
in tum delay treatment delivery schedules and appropriate infection control measures are
increase susceptibility to infection. The inverted strictly followed, such as cleaning equipment
J-shape relationship between interim ty of exercise between clients and avoiding situations in
training and immune function suggests a reduction which survivors are in dose contact with
in immune function with overtraining, exhaustive others who may have colds or coughs. If the
exercise, or both, in athletes.-' However, research program takes place in a public gym setting,
on the effect of exercise on the immune system in dedicated class times fcx cancer survivors
cancer survivors is limited. only will avoid interactions with the general
Two randomized controlled trials examined public.
the effect of exercise on immune function in breast
Cardiovascular System diogram); however, cardiotoxicity is commonly

asymptomatic. Although this does not prohibit
Cancer survivors may be at higher risk for develop engaging in exercise, fitness professionals should
ing or worsening preexisting chronic diseases such recognize the signs of cardiac insufficiency and
as cardiovascular disease (CVD), as a result of a individualize exercise intrnêntions fix people with
sedentary lifestyle prior to diagnosis or a decrease known reduced cardiac function.
in physical activity following treatment- Further There has been little research regarding the
more, there is emerging concern that current hor ability of physical activity to counteract treatment-
monal treatments, such as aromatase inhibitors in induced cardiotoxidty. Although aerobic physical
breast cancer survivors and androgen deprivation activity has been effective in reversing left ven
therapy in prostate cancer survivors, may promote tricular remodeling in poiientB with heart failure,
the development of insulin resistance, metabolic a recent study of aerobic activity for women with
syndrome, and unfavorable cholesterol patterns. An breast cancer recei\*ing adjuvant trastuzumab failed
increased risk of metabolic syndrome is also now to demonstrate a prevention of left ventricular
being documented in survivors of childhood cancer. dimensional and functional reductions (i.e” ejec
Investigators conducting aerobic physical activ tion fraction).*** Overall, more research is needed
ity interventions with breast cancer survivors have to better understand the role of physical activity
reported improvements in CVD risk factors, such in improving CVD risk factors and counteracting
as cardiorespiratory fitness1 策 7•55 and blood levels trratment-inducvd cardiotoxicity in breast cancer
of the systemic inflammatory marker C-reactive survivors.
protein,** with trends toward reductions in resting
heart rate and systolic blood pressure.*' Although Nervous System
these findings may have implications for the risk
of cardiovascular disease in cancer survivors, more The most common neurological effect of cancer
research on the role of exercise to counteract these
treatment is chemotherapy-induced peripheral
side effects is needed. neuropathy. Although the mechanism is not fully
Cancer treatment can also have deleterious understood, some chemotherapy drugs can cause
damage to peripheral nerves. Damage generally
effects on the heart itself. Comnwnly used che
occurs first in sensory nerves and starts in the
motherapy agents, particularly anthracyclines, are
longest nerves (Le., those to the feet and toes).6*
noted to be cardiotoxic (Le., have a deleterious effect
Following are common symptoms:
on the heart and its fuiwtion), causing myocardial
damage and thus affecting the contractility of the • Numbness or reduced sensation
heart In addition, newer biological therapies, such • Painful sensation, such as burning or tingling
trastuxumab (or Herceptin), are also associated
• Increased pain sensitivity to nonpainful
with an increase in cardiotoxicity. An echocardio stimuli
gram is commonly used before, during, and after
chemotherapy treatment to monitor the effects of There is no evidence that physical activity can
these drugs on cardiac function, particularly left improve these symptoms. Peripheral neuropathies
ventricular ejection fraction (LVEF) (i.e., the percent in the feet can impair balance secondary to decreased
age <»( blcxxi expelled from the left ventrjeie during sensation or proprioo?pti()n and can increase the
a systolic contraction).4* The incidence of cardio risk of exercise-related falls. Neuropathy also affects
toxicity with anthracyxlines is reported to be less fingers and hands and may make holding weights
than 10%, with higher risk in older people (over 65 difficult and painful. Depending on the severity of
years) and those taking higher doses of the agents.47 neuropathy, exercises may need to be individualized.
Fitness professionals should note whether their Cancer survivors with foot neuropathies should be
clients have received cancer treatments tKit can cautious when performing weight-bearing actinties
affect cardiac function. In addition, some clients (e.g.z walking on a treadmill). Stationan, bicycles and
may be aware that their cardiac function has recumbent steppers and ergometers are good exer
been affected by treatment (Le., a reduction in left cise modalities for people experiencing loss of bal
ventricular ejection fraction noted on an echocar ance, loss of sensory input, or lower-extremity pain.
Cancer survivors with severe finger and hand neu tors and the relationship these responses might have
ropathy may need spotters when they lift weights. on treatment decisions (as well as physioktgical and
In addition, people with primary brain cancers, psychological outcomes) seems warranted.
metastases to the brain, or tumors affecting the
spinal cord (e.g., spinal cord awnpresskm) may be
impaired in their ability to safely engage in physi Effects of Cancer Medications
cal activity. People with these conditions may have
impairments in balance, cognitive processing, and or Treatments on Designing
ambulation, witti a subsequent risk of falling. This
content is beyond the scope of this chapter.
an Exercise Program
Cancer survivors may face additional challenges to
Hematological System participating in exercise programming related spe
cifically to cancer treatment or ongoing medications
Exercise is thought to stimulate improvement that are commonly prescribed to cancer survivors
in hematological response, such as an increased foUonving chemotherapy or radiation. Three issues
hemoglobin level; however, the observed response that exercise specialists should be aware of are (1)
is quite heterogeneous in the general population. thermoregulatory, or vasomotor, symptoms related
Anemia (Le., a deficiency in the amount of oxygen- to abrupt changes in hormone levels; (2) musculosk
carrying hemoglobin in the red blood cells) is a eletal effects that can cause)oint pain; and (3) issues
common side effect of cancer treatment and can around bone health and the fact that some cancer
result in fatigue and reduce physical function. Neu survivors may have an increased risk for osteopenia
tropenia (i.e.# a reduction in neutrophils, which are and osteoporosis.
white blood cells important for combating infection)
is another common side effect of cancer treatments,
along with a reduction in platelets levels (thrombo
Thermoregulatorôr
penia). Exercise may play a role in improving these Vasomotor, Symptoms
hematological issues in cancer survivors; however, Hot flashes are common side effects of abrupt
the research is limited to date changes in hormonal levels (i.e., prrmaturc meno
Dimeo and colleagues7,1 compared people pause in premenopausal women undergoing
receiving high-dose chemotherapy and stem cell treatment for breast cancer or medical or surgical
transplantation; one group used cycle ergometers androgen ablation in men undergoing treatment
attached to their beds (30 minutes per day), and the for prostate cancer). Hot flashes are sudden feelings
other group did not exercise. The exercise group of heat, sudden sweating, and charge in skin color
had a reduction in the duration of neutropenia and (to pink or red). Hormonal replacement therapy is
thrombopenia, as well as fewer days of hospitaliza highly effective in alleviating vasomotor symptoms
tion. In a small randomized controlled trial during associated with menopause, but is contraindicated
radiation treatment, brvast cancer survivors in the in breast cancer survivors.
aerobic exercise intervention had a 6.3% increase Research on the role of physical activity in help
in VOjnax compared to a 4.6% decline in those in ing to alleviate these symptoms has been limited.
the pUcebci stretching control group. The exerci*e Observational studies of people without cancer
group also had increases in red blood cell count, suggest that women who are more physically
hematocrit, and hemoglobin, whereas those in the active report lower rates of hot flashes.73 However,
control group experiefKtd declines in these blood exercise intervention studies in postmenopausaI
measures.71 women have reported mixed results/4 with some
A small randomized controlled trial of breast reporting an increase in the severity of hot flashes in
cancer survivors posttreatment showed no change the exercise group compared to the control group’
in hemoglobin concentration or hematocrit over This increase in symptoms has been attributed to an
an eight-week combined aerobic and resistance increase in core body temperature during exercise
intervention compared to control. More research and a further reduction in systemic levels of the
regarding the role of exercise on hematological fac female hormone estrogen secondary to the associ
ated weight loss during the study. Postmenopausal activity accordingly if certain activities or doses
women convert other steroid hormones to estn^gen worsen joint pain. Also, because joint pain can
in fat tissue. A loss of body fat can reduce estrogen occur as a result of bone metastasis, a new onset of
levels further, exacerbating the hot flashes. Research joint pain should be investigated before continuing
on hot flashes in men, due to either reduced testos exercise.
terone with normal aging or secondary to ADT, is
very limited, and no physical activity intervention
studies have been reported.
Bone Health 乂
Fitness professionals should explain to clients Bone loss is a potential health concern for cancer
the negative effects that high ambient temperature, survivors (particulariv breast and prostate cancer
relative humidity, and heavy clothing can have on survivors receiving hormonal treatments). Bone
exercise responses, tolerance, and symptoms of hot mineral densi^ is lower in men undergoing andro
flashes.7* Ambient temperature is thought to con gen deprivation therapy for prostate cancer than it
tribute to the frequency and severity of hot flashes, is in agr-matche'd controls. The severity of bone loets
so access to fans or air-conditioning may be helpful increases vsith the duration of androgen deprivation
in counteracting the rise in body temperature associ therapy.*4 Early menopause and hormonal therapy
ated with physical activity. In addition, loose-fitting result in increased rates of osteopormis and osteo
clothing and materials that allow air circulation penia in breast cancer survivors.처 **•' Pharmaceutical
around the skin may also be helpful. treatments to reduce bone loss, such as bisphospho
nates, although highly effective, are asscxriated with
Musculoskeletal Effects广
side effects such as indigestion. Weight-bearing
activities play an important role in bone health
Arthralgia, or joint pain, is a commonly reported side across the life span, by promoting an increase in
effect of many types of cancer treatments, includ bone mineral density. Mechanical stresses appbed
ing chemotherapy drugs (such js tnxanes, cyclo- to bones stimulate the preservation of existing bone
phospamide, and cisplatin人 fiolony-stimulating and the apposition of new bone minerals. Further
factors (used to treat neutropenia), and hormonal more, by improving muscular strength and physical
therapies (particularly aromatase inhibitors such function, exercise may help prevent falls in people
as anastrozole, letriwole and exemestane, which with osteopenia or osteoporosis.M,
are widely used for breast cancer treatments). The Two randomized controlled trials in breast cancer
cause of joint pain with thesie agents is not well survivors have shown that moderate-intensihr aero
understood; however, in the case of aromatase bic activity attenuated the bone loss in the spine or the
inhibitors, the resulting estrogen deficiency is whole body seen in the usual care control groups.14■ 田
thought to be a cause, and this is under investiga Two rvcvnt randomized controlled trials examined
tion. Pharmaceutical treatments, such as nonste the effects of exercise in comparison to or in addition
roidal anti-inflammatory drugs (i.e” ibuprofen> to bisphosphonate treatment.*3 •* In one 24-month
to manage pint pain have bcm commonly uacd randomized amtrolled trial, poeitmencvpausaJ breast
but have additional side effects.77 In noncancer cancer survivors (n - 249) were randomized to medi
populations (i.e.z people with osteoarthritis or cation only (a combination of a bisphosphonate drug
fibromyalgia), exercise has been shown to improve called risedronate, plus calcium and vitamin D) or
joint pain, although the mechanism is not clear?* medication plus a resistance intervention designed
As a result, exercise is suggested as a possible to load the spine, hip, and forearms. Improvements
treatment for cancer-related)oint pain; however, in bone mineral density were noted in both groups.
no randomized trial data exist yet. In prescribing There was a greater increase in bone mineral den
exercise for people experiencing cancer-related sity in the medication plus resistance intervention
joint pain, fitness professionals should use the group compared to the medication only group, but
general aerobic and resistance training prescrip this was not statistically significant** The second
tion for cancer survivors. They should also moni study was a 12-month randomized controlled trial
tor their client'，exercise responses and adjust the of women undergoing chemotherapy for breast
exercise dose (i.e.z volume and intensity) and type cancer (n = 62); one group received zoledronic acid
(an intravenous bisphosphonate drug), and the guidelines for cancer survivors. Mtd Sei Sports Exerc.
other maintained a home-based aerobic physical 2010; 42(7): 1409小126.
activity program (mainly walking). In addition, 2. Clinical guidelines on the idtfntificatwn, evaluation,
each participant received calcium and vitamin D.® and treatment of m erweigh* and obesity in adults:
The ev idence rvfxwt NAhonal Institulrs of Health.
The gn)up receiving the bispheuiphonate drug main
Obes R比. 1998； 6 Suppl 2:5IS-209S
tained bone density, whereas the aerobic group had
3. Thompson WR. Gordon Pescatello LS, eds.
significant declines. However, the compliance to the
ACSM'i Cuiddifun for Excrctst 7?sh»tg and Prescrip
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H. Exvrvise for v*aM*moti)r menopausal symptoms. nu*nup4u>al brvast cancvr Mirvivcm with bone Um»n:
CochraneDatahaseUfst R^v. 2007； (4):CD006108. A 24*month randomized controlled trial. Osteoporos
74 Lindh-Astrand LfNcdstrand E, Wyon、i. Hammar M. 2D10; 21(8): 1361
VaM)moh、r symptoms and quality of life in pevvioudy _玄 Kohrt WM, BkxMnfield SA, LitUe KD, Nehton ME,
Mxientar} postmenopausal women randomised to Yingling VR. American College ot Sports Medicine
physical activity or estrogen therapy. Maturitas. 2004; Position Stand: Physical activity and bone health.
3■유.105. Med Sd Sports Em. 2004; 36(11): 19B5-1996.
CHAPTER 5
Cardiorespiratory
Fitness Testing in
Clients Diagnosed
With Cancer
Lee W. Jones, PhD, and Claudio Battaglini, PhD
following:
• Ability to obtain a basic history regarding cancer diagnosis (e.g., type, stage) and treatment
(e.g., surgeries, systemic and targeted therapies). '
• Knowledge of and the ability to recognize the adverse acute, chronic, and late effects of cancer
treatments.
• Ability to obtain medical history for ottier health conditions (e.g., neurological, cardiovascular,
musculoskeletal, pulmonary) that may cooccur and interact with adverse effects of cancer
treatments.
• Knowledge of and ability to discuss physiologic systems affected by cancer and treatment
and how this would affect the major components of fitness, including balance, agility, speed,
flexibility, endurance, and strength.
• Knowledge of how cancer and its treatments may alter balance, agility, speed, flexibility,
endurance, and strength in cancer survivors and ability to select/modify and interpret tests of
these fitness elements.
• Knowledge of how cancer and its treatments may affect body composition in cancer survivors
and ability to seiect/modify and interpret tests of body composition in cancer survivors.
73
• Knowledge of categories of patients that require medical clearance prior to testing or exercise
prescription.
• Knowledge of cancer-specific relative and absolute contraindications to exercise testing.
• Knowledge of the combined effects of aging and cancer treatment on exercise capacity and
selection of appropriate testing modalities and interpretation of results.
Research and clinical interest in the role of physical as in those with chronic diseases such as cardio
activity and structured exercise training interven vascular disease, type 2 diabetes, and respiratory
tions for cancer survivors has increased dramati disease，*
cally over the past decade (as described in chapter
4). Furthermore, exercise is becoming recognized as
an integral component to manage the unique issues Administrati 에 of
and concerns faced by the rapidly growing number
of cancer survivors in the United States. With this CardiorespiraWry Fitness
growing interest comes an increased need for the
assessment of cardiorespiratory fitness in this popu
Testing
lation. The objective measurement of cardiorespira Several critical steps must be followed when admin
tory fitness is gaining recognition as an outcome of istering cardiorespiratory fitness testing. This sec
significant importance in clients diagnosed with tion looks at those steps—specifically, the sequence
cancer.1 Cardiorespiratory fitness testing in clients of testing procedures and the selection and utility
who have been diagnosed with cancer may be used oi tafHng.
to do the following:
• Evaluate the cardiorespiratory effect!* of Sequence of Testing

medical treatments associated with a cancer
diagnosis
Procedures ’
• Prescribe and develop accurate excfcif*c regi There are many factors to consider when assessing
mens for clients diagnosed with can<rr a cancer survivor4s cardiorespiratory fitness. Major
considerations include the client’s demographic
• Evaluate the efficacy of exercise training regi
mens on cardiort*spira tory fitness and medical characteristic!、the client's needs and
desires, the setting, and available equipment.1
Several tenns are used to describe cardiorespira Fitness professionals must make sure to assess
tory fitness, including rxfrciê/trpadty, otrubic p(n(vr, the pn*scnce and degree of currently experienced
cardiorespiratory fitness, and exercise tolerance; these side effects that may affect test results, such as
terms are often used interchangeably. fatigue, anemia, neuropathy, pain, shortness of
Cardiorespiratory fitnvss reflects the integrative breath^ radiation-induced heart dhease, general
ability of the components of the cardiopulmonary cardiovascular issues, and card iomyopathy from
system (i.e.，heart, lungs, and blood system) to certain chemotherapies (primarily anthracyxlines)
deliver oxygen to the mctabolically active skeletal and targeted therapies (e.g., Hercqjtin). Fitness
musdes? In research and clinical settings, cardiore professionals must also use care in comparing
spiratory fitness is most commonly assessed using cancer survivors to age-matched norms to avoid
maximal exercise testing protcxrols《e.g., cardio discouraging clients. It is always advisable to refer
pulmonary exercise test |CPET] and stress tests), clients to their primary oncologists or general
whereas in nonclinical settings cardiorespiratory practitioners for initial cardiovascular and gen
fitness is assessed using submaximal tests (e.g., eral comorbidity screening. Further, clients with
walk tests, age-predicted heart rate tests).3 Cardio remarkable medical histories (e.g., hypertension,
respiratory fitness is a primary health indicator in heart disease) should have a physician supervise
humans and has consistently been associated with a classic stress test to ensure optimal safety of
morbidity and longevity in healthy people, as well exercise testing and training. Despite all of these
Cardiorespiratory Fitness Testing in Clients Diagnosed With Cancer 75
comprehensive medical and physical examination

당 Take-Home Message at diagnosis and prior to the initiation of cancer
서■隊 Given that this may be the first therapy (if appropriate). As such, the oncologist
cardiorespiratory fitness test will likely have thorough knowledge of any major
clients have performed, signifi health complications or other comorbiditics that
cant learning effects can be ex can be potential contraindications for cardiorespi*
pected. In other words, clients will invariably ratory fitness testing. Thus, obtaining oncologist
record a higher fitness score on a repeat as approval for cardiorespiratory testing should, in
sessment because they are more comfort most circumstances, circumvent the need for addi
able with the testing procedures. Conducting tional evaluation. Cancer survivors are typically
two tests at baseline may ensure the most older and commonly present with a diverse range
accurate preexercise training fitness mea of cardiovascular or musculoskeletal complica
surement (and subsequent exerase pre- tions (or both); thus, preexercise screening and the
scnption). use of appropriate testing modalities are critical to
maximize tiie safety of exercise testing as well as
the accurate interpretation of results for older cancer
survivors.*4*
caveats, it is possible to provide a general outline
Following is one recommended sequence of car-
of exercise testing.
ôrewiratory fitness testing procedures:
The testing appointment should begin with an
assessment of resting physiological parameters such 1. Preactivity screening questionnaire (e.g.,
as heart rate and blood pressure. Next, body weight PAR-Q or PARmed-X) and other question
and height as well as body composition (if appro naires to evaluate medical history
priate) should be recorded according to standaid
2. Resting heart rate
guidelines. Finally, after an initial warnvup period
3. Resting blood pressure
(approximately five minutes), the cardiorespiratory
fitness assessment (whiche\rer test is mostappropri- 4. Anthropometries (e.g.^ body weight, circumfer
ate) can be initiated. The professional should ences)
perform physiological aêssments only after the 5. Cardiorespiratory fitness testing (e.g., stress
patient has completed a physical activity ques test, 6-minute walk test)
tionnaire such as the Physical Activity Readiness 라
Questionnaire (PAR-Q； figure 5.1) or PARmed-X. In addition (b maximizing exercise testing safety,
fitness professionals should also ensure that clients
no< engage in behaviors that influence the results
of the cardiorespiratory fitness test itself. For
Take-Home Message example, dients should be asked to abstain from
Cancer therapy can drastically behaviors (e.g., drinking caffeinated beverages,
身 change heart rate response to smoking, exercising) that may alter heart rate and
exercise. Thus, fitness profes blood pressure responses to exercise? Abstinence
sionals should indude addition* from indications that may alter these parameters
al parameters that provide supplemental as is not required because exercise testing is not used
sessments of exercise effort or stress such for diagnostic purposes in dients with cancer. To
as blood pressure, rating of perceived exer this end, fitness professionals should be well versed
tion, and oxygen saturation. in cancer-specific medications as well as general
medications that may affect the exercise response. A
questionnaire to the clienfs primary care physician
Thoroughly evaluating a clients medical history to inquire about any exercise response-modifying
prior to selecting a test to evaluate cardiorespira medications that the client may be taking can facili
tory fitness will maximize safety. As with other tate this process. See figure 도2 for an example of
chronic conditions, clients with cancer undergo a such a form.
Figure 5.1
PAR-Q & YOU

《鳥 Quettionnaira for P«opl« Agvd 15 to 69)
41 6w hetUthv. <Krc4Sinolv nute mocnc i re startirx)io bcconie more idrve every d4V. BtVM] HKXC rS Vff v Mte tor mo닛
SW ptt)pl€ SnOlA1 check wfh ther docior before they 1lart becomn9 much more physical^ ac어
mewe phyw^f adive 1>un 바u m, start bf，inswccinQ the seven quc$t_ are between thi
d 的. the fWIQwMtd1 mu |f you should chedk with VOUF de hrlnrr _ou start ■ you are over 69* ytdfs erf Mt. 3nd you Mt nkm used to bernc
«ry actf^. check your doctor.
YES NO
1. Na» yvvr 4«t»r «v«r Mi4 that f««i have a heart <m선Hi«n that yo« *b*eld ««ly d« activity
r*<on»M«W«d by . 4«t»r?
2. Do yo« twl paia ia your chest wrh«n y». 4c physical activity?
□ 1. ■■ the 한a»t month, Imv« 齡 h«d <h»«t p«ia when were ••< doinyacllvfty?
4. Do yo« l«s« yovr b«lM<e b«<«MSc of diui««ss or 4« ymi ever I»m coutiMMMS?
5. Do yo舊 b«v« a b««c •，j«iM (f*r «aam|H«, k«<k, ha«« *« 1“辭) that <o«M be ma4e __rs« by •
<“_，• i« ”activity?
|~1 <• l» your 4«<tor cvrrestly preMribi*，d『，9« (for «aampl«, water pills) for your pr«ss»r« •，heart cm.
쎄 on?
1. D« yo« Iumw of etlier rMt«« why y*« m. -o activity?
YES to one or more questions
yOU 여必떠 «ou"hew““nd •세<»«的«

I • Ybu bt ibie to do ■，하 Mliv*y you oont
answered
• 白nd out aKch coiWMfvty proonnB i es^c ar
DELAY BECOMING MUCH MORE 鳥HIVE
No ch«i»9es permitted. Yo« arc enco«<a9e<l to p*iot(xopy the PAR-<) but only if you use the entire form.
Note： This ^hyskal activity clearance is v*IM for « of 12 moaths from Um date It is completed
iavalM if ye«r <«Witio« cbMye* »• tb«t yoa wmM ••，，•« TES to My •. the mvm qa«Bti»M
'=CMP SCM n,-

- L***1，化하 t>ec* Hi外Ota어 «mcjefU4.^r^
From ACSM. 2012. ACSM k gutd，to and c«nc«r，un峰nnhip <C*wnp_0n. IL Hwnan Kinetca) From R«)_cal Activtfy ReadkMM OuMtionnave 거
O 2002. Reprmttd w_ parmiMion tor *、• Canadan Society to，Emicim Phytiolo0y «nmvcaap.c»4o«mtMp
76
Figure 5.2 Me(Hcati매 니St
Name:
Please check any medication you presently take on a regular basis and provide the following information.
Cancer-Specific Medications
If you are currently undergoing radiation therapy, please check the box in the following table and provide
dose and schedule.
Date of
Dose and discontinued
Medication Name of medication(s) schedule Date started UM
□ Chemotherapy
□ Immunotherapy
□ Hormonal therapy
□ Other cancer therapy
□ Radiation therapy
Other Medications and Supplements

Please make sure to include over-the-counter drugs such as Tylenol. aspirin, and vitamins under Other
medicines.
Baseline testing: Date/time: l
Date of
Medication Name of medication(s) schedule Date started use
□ Medicine tor heart
□ Medicine tor blood

pressure
□ Medicine for breathing
Of lungs
□ Mediane for diabetes
□ Medians lor ulcers
□ Medicine for arthritis
□ Other medicines
□ Supplements
《continued}
Medication List (continued)
Follow-up testing: Date/time:
Date of
Medication Name of medication(s) schedule Date started use
Medicine tor heart
Medicine for blood

pressure
Medicine lor breathing
or lungs
Medicine lor diabetes
Medicine for ulcers
Medicine for arthritis
Other medicines
Vitamins and
supplements
Fitness professionars comments:
Fitness professional's name (Please print):
Fitness professional's signature:
Date:
From ACSM, 2012. ACSM'a io mwom and cancer 醜p (Champaign. IL Human Kmettca).
(2) estimated measurement of oxygen consump

Take-Home Message tion using standard formulas from the highest
Because cancer survivors are treadmill or cycle workload achieved (figure 5.4).
often older, have received some Both types of maximal tests require that the client
form of aggressive therapy, and
achieve volitional (exhaustion or symptom limita
tion, and both provide an accurate determination
may present with a diverse range
of comorbid conditions, they may find a car of cardiorespiratory fitness. It is important to clarify
diorespiratory fitness test intimidating. Thus, that maximal cardiorespiratory tests are not used
fitness professionals may need to take extra for cardiac or pulmonary diagnostic purposes in the
time to fu_y describe the test procedures and
oncology setting.1 Once a maximal test is chosen, it
provide appropriate encouragement and re
M imperative that it be conducted in a clinical set
assurance before, during, and after testing
ting with the appropriate equipment and qualified
procedures. personnel.
Submaximal tests predict cardiorespiratory fit
ness based on the workload achieved at a given
predetermined submaximal heart rate. The decision
Selection and Utilitv to conduct maximal or submaxinw! exercise tests
should be determined following the careful con
of Testing sideration of several factors including the purpose
Several methods are available f(Y evaluating cardio
respiratory fitness in clients with cancer (table 5.1).
This section discusses the use of laboratory-based
tests such as cardiopulmonary exercise testing as
well as field-based tests including the 6-minute walk
test. This section also discusses various parameters
to consider when choosing a test modality for the
evaluation of cardiorespiratory fitness in a client
diagnosed with cancer.
봉
Take-Home Message
Because clients with cancer
are typically older and have
received treatments that may
have affected their balance, fit
ness professionals should choose the most
appropriate cardiorespiratory fitness test ex
ercise modality and have at least two quali*
fied exercise physiologists at every lest.
The first major consideration is whether to

perform a maximal (with direct or estimated
measurement of gas exchange) or submaximal
cardiorespiratory exercise test. Maximal cardiore
spiratory tests can be divided into two categories:
(1) direct measurement of oxygen consumption
via incremental cardiopulmonary exercise test Figure 5.3 Cardiopulmonary exercise test with
with gas exchange measurement (ftgure 5.3》, or gas exchange colection.
TABLE 5.1 Exercise Test Modalities
Maximal
CPET Stress Test
Direct measurement Ybs No
ofVO2
Estimated No Yes, estimated from highest workload
measurement of V02 achieved during the test
Equipment • Expired gas measurement system • Electronically braked cycle
• ElectrontcaNy braked cycle ergometer or motorized treadmiN
ergometer or motorized treadmill • 12니ead ECG
• 12니ead ECG • Pulse oximeter
• Pulse oximeter • BP monitoring
• BP monitoring
Cost Relatively expensive Reasonable
Test duration 8-12 minutes 8-20 minutes
Description of test Incremental exercise with expired gas Incremental exercise until volitional
analysis until volitional exhaustion or exhaustion or symptom limitation.
symptom limitation.
Submaximal
6- or 12-minute
Age-predicted HR walk test Constant load test*
Direct measurement No No No
ofVO2
Estimated Yes. estimated from the Yes. estimated from No
measurement of V02 worktoad achieved at a blood pressure and
predefined HR (70-85% heart rate response
HR J during test
Equipment • Electronically braked • 30*meter hallway or • Electronically braked
cycle ergometer or corridor cycle ergometer or
motorized treadmil • Heart rate monitor motorized treadmill
• Heart rate monitor • Pulse oximeter • Heart rate monitor
• Pulse oximeter • Stopwatch • Pulse oximeter
• Stopwatch J • Stopwatch
Cost Reasonable Inexpensive Inexpensive
Test duration 8-20 minutes 6 or 12 minutes 5-30 minutes
Description of test Incremental exercise Subject walks as far Subject pedals for as
until predefined HR as possible in 6 or 12 long as possible at
(70■公5% HR_J minutes predetermined workload
achieved (50-70% workload다)
measured during
incremental CPET
•Can ba performed an~ a CPET (cantopulmonary mroM teat).
Adapaed toom L.W. Joam •< M. 2008, XantorMpiratory eiMCMe imang in ciinieal oncology fMMfch: tyMmatic review and practee
mcommandations.* Lancet Ona貨)gy 9<8): 757-765.
80
VCKpeak, is recommended because it provides the

most accurate assessment of cardiorespiratory fit
ness (figure 53). If cardiopulmonary exercise testing
is not available, estimating VO2peak through stress
testing is an excellent alternative (figure 5.4). Both
cardiopulmonary exercise testing and traditional
stress testing are reliable for identifying and detect
ing undiagnosed cardiovascular conditions, which
submaximal cardiorespiratory fitness tests cannot
do. It is noteu orthy to mention that cardiopulmo
nary exercise testing procedures require regular
equipment calibration to ensure that the test data
are reliable and valid.
Despite the advantages of maximal cardiorespi-
ratory fitness testing submaximal testing (without
gas exchange measurement) is also a valuable
method to assess cardiorespiratory fitness in cli
ents with cancer. These tests can be performed in
a controlled laboratory, clinical setting, or field
test (outside of a Laboratory or dink setting). Field
tests include age-predicted heart rate tests and 6-
or 12-minute walk tests; these tests are rehtively
easy and inexpensive to administer. Such testing
may be appropriate in frail or elderly patients, or
where appropriate nwdical supervision to conduct
numerous tests in a nondinic-based setting is not
Figure 5.4 Traditional exercise stress test.
available.1 However, the investigator or clinician
must be cautious when interpreting the results of
of testing (research investigation or exercise reha- such tests. Submaximal testing relies on an extrapo
bilitation)# the setting, and the patient population. lation of cardiorespiratory fitness from the work rate
I'heae “ctor、are reviewed in detail in the following achieved at a given submaximal heart rate. Thus,
sections. a significant potential for error exists because of
the 10- to 12-beats-per-minute standard deviation
Purpose of Testing in maximal heart rate in nonnal subjects as well
Cardiorespiratory fttness testing is as age-mediated errors in determining maximal
used for research applications in heart rate? There may be even greater variation
setting. However, cancer exercise rehabilitation is in patients diagnosed with cancer who have been
becoming a more recognized component of clinical treated with cancer therapies or other medications
cancer management?2 Thus, the need for cardiore that may affect heart rate control.11***
spiratory fitness testing outside of predominantly Submaximal tests can also be used to assess
research applications is likely to increase over the functional capacity, in terms of distance walked or
next decade. time to fatigue. For example, 6- or 12-minute walk
In clients with cancer, cardiorespiratory fitness tests provide a simple, safe, and inexpensive objec
testing is used primarily to provide (1) an objec tive assessment that can be performed in numerous
tive determination of peak oxygen consumption research and clinic settings. However, walking
(VO：peak) or submaximal prediction of cardiore tests were originally designed to assess functional
spiratory fitness, and (2) an exercise training pre capacity in clients with severely compromised
scription and cardiorespiratory fitness evaluation functional status, such as tho^c with chronic heart
following exercise rehabilitation. In both settings, failure or chronic obstructive pulmonary disease.
use of cardiopulmonary exercise testing, to assess As such, these types of tests may not be sensitive
82 ACSM's Guide to Exercise and Cancer Survivorship www.acstn.org
enough to evaluate the effects on clients who have monary exercise testing provides the safest and
been diagnosed with early-stagc cancer and who mmt robust assessment of cardiorespiratory fit
do not have any additional comorbidity. A ceiling ness, selection of this test appears prudent. Special
effect among these clients may occur because such consideration should be given to clients currently
tests are unable to sufficiently stress them to detect undergoing scime form of cancer therapy, especially
whether changes in cardiorespiratory fitness have those receiving chemotherapy or radiotherapy, or
transpired.1 For information and practical guide both, as these therapies can negatively affect several
lines on accurately administering a 6-minute walk organ components that determine cardiorespiratory
test, please visit www.thoracic.org/statements/ responses to exercise.
resources/pfet/sixminute.pdf.
Must important in cluxMing the appropriate fit
ness test is to make sure the test matches the client’s
goals. For example, if the client is new to exercise
Exercise Testing Safety
and has a goal of beginning a walking program, then Safety is a vital comideration when selecting tests
a 6-minute walk test is much more appropriate than to assess cardiorespiratory fitness in clients with
a maximal treadmill test. cancer. Unfortunately, larg^-scale evaluations deter
mining the safety of the various types of available
Setting cardiorespiratory tests for people with cancer have
The setting for the cardiorespiratory fitness test not been conducted.* Yet, previous research has
requires careful consideration. The two broad set indicated that maximal and submaximal exercise
tings are clinically based (laboratory) facilities and testing is, for the most part, a safe procedure for
nondtnicaliy based (field) facilities. Because maxi this population.1 Nevertheless, many clients with
mal cardiopulmonary exercise tests arc relatively cancer receive intensive medical therapies that may
expensive and require specialized personnel and elevate the risk of an exercise test-related compli
equipment and medical superv ision, submaximal cation. Thus, fitness professionals must employ
tests may be desirable in nonclinical settings. How strict screening (eligibility) and testing procedures
ever, without appropriate medical supervision, to optimize client safety. Specifically, the safety of
even submaximal tests should only be conducted cardiorespiratory fitness testing ultimately depends
with clients classified »low risk of exercise-related on two factors: (1) eligibility criteria and client selec
adverse events. Ideally, cardiorespiratory fitness tion, and (2) test administration and methodology.
testing performed in a ebnieal setting should use
cardiopulmonary exercise testing because these
Eliaibility Criteria and Client
tests provide comprehensive and the most accurate
information regarding cardiorespiratory fitness
Selection
condition. Available absolute and relative contraindications to
cardiorespiratory fitness testing published by the
Patient Population ASCM as well as other organizations (e.g., American
Clients with cancer vary widely in terms of progno Thoracic Society) are appropriate to apply to clients
sis, demographics, medical treatments, and extent with cancer. However, added to these contraindica
of comorbid disease. Thus, fitness professionals tions shtniki be the presence of extensive skeletal and
should thoroughly consider each client's situation to visceral metastases and untreated anemia (table 5그》.
select the most appropriate cardiorespiratory fitness As mentioned previously, for sa^ty reasons,
test, in general, cardi이mlmonary exercise testing is clients must be cleared for cardiorespiratory fit
likely the best method to assess cardiorespiratory ness testing by their oncologist or primary care
fitness in the majority of clients with cancer. physician. The information fitness profession
Literally hundreds of therapies are used in the als should have includes, but is not limited to,
oncology setting. Unfortunately, researchers do clinical diagnosis, stage of disease, prior or current
not currently have a good understanding of how treatments, physical activity profile, appropriate
these therapies affect the components that govern laboratory tests (e.g., hemoglobin )80*110 mg/dL]K
cardiorespiratory fitness.2 Given that cardiopul complete blood counts), determination of exercise
TABLE 5.2 Absolute and Relative Contraindications for Exercise Testing

Absolute Relative
Acute myocardial infarction (3-5 days) Left main coronary stenosis or its equivalent
Unstable angina Moderate stenotic valvular heart disease
Uncontrolled arrhythmias causing symptoms or Severe untreated arterial hypertension at rest
hemodynamic compromise (>200 mg Hg systolic. >120 mm Hg diastolic)
Syncope lachyarrtiythmias or bradyarrhythmias
Active endocarditis High-degree atrioventricular block
Acute myocarditis or pencarditis Hypertrophic cardiomyopathy
Symptomatic severe aortic stenosis Significant pulmonary hypertension
Uncontrolled heart failure Advanced or complicated pregnancy
Acute pulmonary embolus or pulmonary infarction Electrolyte abnormalities
Thrombosis of lower extremities Orthopedk: impairment ttiat compromises exercise
pefformance
Suspected dissecting aneurysm Untreated anemia (hemoglobin (evel between 8
and 11 gm/dL)
Uncontrolled asthma
Pulmonary edema
Room air desaturation at rest s 85%
Respiratory failure
Acute noncardiopulmonary disorder that may affect
exercise performance or be aggravated by exercise
(i.e., infection, renal fariure, thyrotoxicosis)
Mental impairment leading to inability to cooperate
Evidence of extensive visceral or skeletal
metastases, or both
Adapted from Amencan Tbocacc Society/Amencan CoMege of Oest Physcian&. 200표 W&ACCP Statement on cantopuimonary atetcise lestng.*
Amencan Journal of AesptrMrr and CrttxM C^re Medcrw 167(2): 211-77. f
contraindications, and oncologist or physician to ensure that the test chosen is administered cor
approval. Most of this information can come from rectly and safely. Choosing appropriate exercise
routine oncology visits or from the client's medical equipment and testing protocols and monitoring
history report. patient exercise response play fundamental roles
A physical activity profile will help the fitness in ensuring a successful test.
professional choose an appropriate cardiorespira- Two types of exercise equipment can be used to
tory exercise test protocol (maximal or submaximal) evakiate cardiorespiratory fitness in clients with
and modality (cycle ergometer or treadmill). In cancer: treadmill (see figure 52) and cycle ergometer
nondinical settings, clients must receive physician (figure 55). For most laboratory settings, a treadmill
clearance or complete a preexercise screening ques- is used when conducting maximal testing. If a tread
ticmnaire (e.g., PAR-Q, PARnwd-X) prior to testing. mill is not available for use, then cycle ergometry
is recommended.
Test Administration and Motor-driven treadmills provide progressively
increasing exercise intensity through a combina
Methodology tion of speed and grade (elevation》according to
Once the fitness professional has determined the selected protocol. Treadmill-based exercise tests
whether cardiorespiratory testing is appropriate for are attractive because walking is a more natural
the client, the next most important consideration is and familiar activity than cycling for most people.
• It requires less coordination and balance than

treadmill walking.
• Work rate is quantifiable.
Several protocol options are available to ensure

the precise evaluation of oxygen consumption. Most
protocols can be used with either a cyde ergometer
or tTcadmill. Generally, protocols can be classified
into two broad categories according to the applica
tion of workload:
• Constant increments (aU clients use the same

workload increments)
• Individualized increments (variable workload
increments based on client characteristics)
Individualized protocols are recommended for

clients with cancer given the expected large varia
tion due to differences in cancer type, treatment,
demographics, and the presence of other comor-
bidities. Multiple tests for the same client over a
prolonged period of time should occur on the same
exercise equipment and at the same time of the day,
and preferably, should be administered by the same
fitness professional.
Take-Home Message
Because a cardiorespiratory test
Figure 5.5 Cycle ergometer.
will likely be a novel experience
for the vast majority of clients
Exercise testing on a treadmill may elicit a higher with cancer, a lollow-up phone
physiological response, thus providing a more call the day after testing is recommended to
accurate assessment of cardiorespirat<wy, fitness and ensure that they are feeling well and not ex
increasing the possflhlity of uncovering potential periencing any unexpected signs or symp
underlying cardiac symptoms. Of course, safety toms.
is the highest priority. The main disadvantage*
of treadmill exercise testing are the difficulty of
quantifying external work rate and the coordina*
To maximize client safety during maximal or
tion and balance requirements. The latter point
submaximal testing, it is critical that several physi
is an important consideration in older clients and
ological parameters be assessed before, during, and
those suffering cancer treatment-related toxicities
following the cardiorespiratory fitness assessment
that may affect balance and coordination. These
(table 5.1). In addition, the physiological responses
toxicities may also alter heart rate and blood pres
to exercise will be very informative when design
sure responses to exercise.
ing a client*specific exercise training prescription
In contrast, cardiorespiratory fitness testing
(if appropriate).
administered on a cyde ergometer offers the fol
Clearly, the level (extent) of physiological moni
lowing advantages:
toring will be determined by the type of exercise
• It is less likely to introduce movement and test selected: maximal versus submaximal. For
noise artifact into exercise response measures. example, heart rate, blood pressure, pulse oximetry,
and EKG monitoring are recommended for all cli 3. ATS/ACCP statement on cardiopulmonary exercise
ents prior to, during^ and following maximal exer testing. Am / Rr〒f，Crit Gvr Mol. 2003; 167(2卜 211-
277.
cise testing.3 Client monitoring with these devices
will allow early detection of exercise-associated 4 Kavanagh T, Mertens DJ, Hamm LE et al. Prediction of
abnormalities <)r complications that may mandate
kmg-tenn prognosis in 1X169 men wferrvd for cardiac
rehabtlitation. Circulation. 2002; 106(6): 666-671.
test termination, while also providing detailed
5. Myers J, Prakash M, Froelicher V, Do D, Partington S,
information on patient response to various exercise
Atwood JE. Exercise capacity and mortality' anumg
intensities.
men rvferwd for exercisie testing. N Engl / Med. 2002;
Submaximal exercise responses during a 346(11):793-801.
maximal cardiopulmonary exercise test can also
6. Gulati M. Black HR. Shaw LJXdl. The prognostic vjilue
provide valuable data that can identify causes of of a nomogram for exerQM^ capacity in womun. N Engl
poor cardiorespiratory fitness and assist with the I Mtd. 2005; 353(5): 448^5.
individualization of exercise prescriptions. In addi 7. Blair SN, IGimpcrt JB* Kohl HW, 3rd, ct al. Influences
tion, heart rate and pulse oximetry (capacity of the of cardiiMvspiMitoffy and i>ther prvcurwn> on
heart to deliver O2 per beat) supply information cardkn aM?ular diMrase and all-cause mortality* in men
regarding the cardiovascular response to exercise. and women, fama 1996； 276(3): 20&-210.
However, EKG and physician monitoring are not 8. Warburti»n Dl£, Nicol CW, Brvdin SS. Health benefits i>f
required when conducting submaximal exercise phys>k«il activity： The evidence. CMAJ. 2006； 174(6)：
S01-809
tests in asymptomatic patients exercising within
their normal levels of exercise. Nevertheless, 9. Jonesi LV\, Eve* ND, Mackey JR, et al. Safety and
feasibility of cardiopulmonary exercise testing in
even during field-based assessments such as 6- or
patients with advanced cancer. Lung Cancer. 2007;
12-minute walk tests, heart rate and pulse oximetry 55(2》: 225-232.
are still advisable during exercise, as is blood pres
10. Jones LW, Haykowsky M, Peddle CJ, et al. Cardio
sure monitoring before and after testing, vascular risk profile of patients with HER2/neu-
positive brvabt cancer treated with anthracydirw-
taxane-containii^ adjuvant chemotherapy and/or
Summary trastuzumab. Cancer Epidemiol Biomaricers Prtv. 2007;
16(5): 1026-1031.
Several tests are available to measure cardiorespira* 11. Jones LW, Haykows—M, Rituskin EN, et al. Cardio
tory fitness in clients with cancer. The selection of vascular reserve and risk profile of postmenopausal
a cardiorespiratory fitness test should be governed women after chcmoendocrine therapy for hormone
rvceptiw-positive operable brvast CAncer. Oncobgist.
by several factors including the chenfs medical and
2007; 12(10): 115〜11M.
demographic characteristics as well as the test set
12. BrownJK. ByersT, DoyleC,etal. Nutrition and physi-
ting and avail.ible equipment. Such considerations
activity during and after cancer trvatment： An
are critical for the safe, feasible, and precise assess Amerkan Cancer Society guide for informed choices.
ment of cardiorespiratory fitness in clients with CA Cancer / Clin 2003; 53(5h 268-291.
cancvr. When correctly administered, cardiorw»pira- 13. Zacharia« R, Paulsen K, Mehisen M, Jvn»en AB,
tory fitness testing can be a valuable tool to aid in Johansson A, van der Maase H. Chemotherapy-
the comprehensive cardiovascular and functional induced nausea, vomiting, and fatigue一The role of
assessment of clients with cancer as well as the individual differences rvUtvd to semory perception
and autonomic tvactivity. Piifchother Psydws이”- 2007;
design and m<Miitoring of exercise presenptions.
76(6): 376-384.
14. Mcinardi MT, van Veldhuisen D), Givtvma JA. et
References al. Prospective evaluation of early cardiac damage
1. Jones LW, Eves ND, Haykowsky M, Joy AA, Douglas induced by epirubicin-containing adjuvant chemo
PS. Cardiorespiratory exercise testing in clinical therapy and locoregional rodiotherupy in brv^st
oncokigy research: Systematic review and practice 1 am » r patjrnts / Clm 2()01, 1€>( 10) 그74“-
rvcummendations. Umat Oncol. 2008; 9(8): 757-765. 2753.
2. Jones LW, Eve« ND, Haykowsky M, Frvedland SJ, 15 Motrow CR，Hickok JT, DuBeshter B. Lipshultz SE
Mackey JR. Exercise intolerance in cancer and the Change* in clinical nwa)iun*« of autonomic nervmiK
role of exercise therapy to reverse dysfunctian. Lanett system function related to cancer chemotherapy-
Oncol. 2009； 10(6): 59fr€05. induced nausea. / Auton Nerp Syst. 1999； 78(1 )： 57-63.
CHAPTER 6
Exercise Prescription
and Programming
Adaptations
Based on Surgery, Treatment,
and Side Effects
Kathryn Schmitz, PhD, MPH
following:
• Knowledge of current Amencan Cancer Society guidelines for exercise in cancer survivors.
• Knowledge of how common cancer treatments affect the ability of cancer survivors to perform
exercise, and how to adjust programs accordingly.
• Ability to describe benefits and risks of exercise training in the cancer survivor.
• Ability to recognize relative and absolute contraindications for starting or resuming an exercise
program, and knowledge of when it is necessary to refer participant back to an appropriate
care provider.
• Knowledge, skill, and ability to modify exercise prescription/program based on:

a. current medical condition
b. time wee diagnosis on or off adjuvant treatment
c. type of current therapies (e.g., no swimming during radiation)
87
d. type and recency of surgical procedures (e.g., curative or reconstructive)

e. range of motion
f. presence of implants
g. amputations/fusions
h. effects o< treatment on all elements of fitness (agdity, speed, coordination, flexibility,
strength, and endurance)
i. hematologic considerations (e.g., anemia, neutropenia)
j. presence of a central line (PIC or Port)
k. current adverse effects of treatment, both acute and chronic
l. individuals that may be at increased risk for adverse late effects that could increase risks
assoaated with exercise (e.g., heart failure)
• Knowledge of potential for overtraining with the cancer survivor.
• Knowledge of and ability to use appropriate sun protection tor outdoor programming.
• Knowledge that cancer treatment may accelerate functional decline associated with aging,
particularly in the elderly, and that exercise programming may need to be adjusted accordingly.
• Knowledge of National Lymphedema Network (NLN) 18 risk reduction practices, and exercise
guidelines.
• Knowledge of lymphatic, neurologK^l, and immune system factors in cancer survivors that
may require further evaluation by medical or allied health professionals before participation in
physical activity.
As noted in chapters 2 and 4, the experience of nodes removed and have developed
being diagnosed and treated far cancer results in lymphedema as a result?
numerous phôlogical and psychosocial changes.
Throughout this chapter, the terms physical acth^-
The goal of this chapter w to focus on what those
changes mean with regard to exercise prescription. "y and exercise are ustid interchangeably. Techni-
This chapter will hetp fitness professionals answer cally, physical activity is a more inclusive term that
the following questions: includes multiple forms of movement, including
exercise. a 뉴
• What are the recommendations for exercise
prescription for the general public and how
should this be altered for cancer survivors?
• What knowledge about a cancer survivor
Health Promotkm and
is needed for individualizing that person's
exercise prescription? For example：
Risk of Disease Reducti매
- How does treatment with a cardiotoxic To modify an exercise program for a specific popu-
chemotherapy drug alter a penotVs exer htion, we need to start with something that can
cise prescription? be modified: the recommendations for the general
- How should a fitness professional alter ex public. This sec■由on outlines the current guidelines
ercise prescriptions for survivors at high for exercise prescription from the American College
risk for bone metastases, osteoporosis, or of Sports Medicine, issued jointly with the American
both? Heart Association, as well as the exercise guidance
• What forms of exercise are rvcrnnmended, from the American Cancer Society and the U.S.
and what should be avoided, for those Department of Health and Human Services.
with peripheral neuropathy secondary to The Physical Activity Guidelines for Americans
chemotherapy? developed by the US. Department of Health and
. How should an exercise prescription be Human Services (US. DHHS) indicate that when
modified for those who have had lymph people with chronic conditionssuch as cancer一
Exercise Prescription and Programming Adaptations 89
are unable to meet the stated recommendation based exercise recommendations for promoting health in
on their health status, they should be as physically adults have much in common. They also form the
active as their abilities and conditions allow." An basis for any modification in exercise guidance for
explicit recommendation is to "avoid inactivity/ specific populations such as cancer survivors.
and it is clearly stated that ’’Some exercise is better The goals of these rvcommendatkins are as fol
than none. The key guideline for aerobic activity lows:
from the U.S. DHHS focuses on weekly activity of
• To promote general health
150 minutes of moderMe-intensity exercise, 75 min
• To reduce the risk of chronic diseases such as
utes of vigorous-intensity exercise, or some combi
diabetes, cardiovascular disease, osteoporosis,
nation of the two. Guidance for strength training is
and cancer
to perform two or three weekly sessions that include
exercises for major muscle groups. Flexibility guide
lines, from the ACSM/AHA guidelines and in the
변 Take-Home Message
US. DHHS guidelines for older adults, are to stretch
major muscle groups and tendons on days that Developing exercise prescrip
other exercise is performed.1*3 For further details tions that are specificalty adapt
on the general exercise prescriptions for health for ed tor the unique needs of cancer
adults, see the sidebars that follow. In addition to survivors requires knowledge of
these two specific sets of guidelines, the American exercise prescription guidelines for the gen
Cancer Society recommends that adults engage in eral public. The U.S. DHHS and AHA/ACSM
at least 30 minutes of moderate to vigorous exerdse, exercise prescriptions tor the general public
beyond their usual activities, on five or mor^days form the basis from which any adaptations
of the week. The ACS guidelines further slate that are made for any special population, includ
45 to 60 minutes of intentional exercise five times ing cancer survivors. An important message
weekly is even better for cancer prevention than 30 tor all populations is to avoid inactivity.
minutes" The ACS, ACSM/AHA, and US. DHHS
ACSM/AHA Exercise Prescription for Adults

Aerobic Activity
• Do moderately intense cardiovascular exercise 30 minutes a day. five days a week, or do vigor
ously intense cardiovascular exercise 20 minutes a day. three days a week.
• Moderate-intensity exercise means working hard enough to raise your heart rate and break a
sweat wtiile stil being able to carry on a conversation
• It should be noted that lo lose weight or maintain weight loss, 60 to 90 minutes of exercise may
be necessary.
Strength Training Activity

• Do 8 to 10 strength training exercises, 8 to 12 repetitions of each exercise, twice a week.
• Fo『 older adults (65>), the following recommendations are added:
• If a health professional has toW you that you are at risk of falling, perlorm balance exercises.
• Have an exercise plan.
- Both aerobic and muscle-strengthening activities are critical for healthy agmg.
• Moderate-intensity aerobic exercise means working hard at about a level-6 intensity on a
scale of 1 to 10 (with 10 being highest intensity).
- \bu should stil be able to carry on a conversation during exercise.
Adapted from Hastiell e( M 2DD7*; M.E_ Netacn et aL 20071.
U.S. Department of Health

and Human Services Physical Activity Guidelines
Adults (aged 18-64)
• Adults should do a minimum of 2 hours and 30 minutes a week of moderatedntensity. or 1 hour
and 15 minutes (75 minutes) a week of vigorous*intensity aerobic exercise, or an equivalent
combination of moderate- and vigorous-intensity aerobic exercise. Aerobic activity should be per
formed in episodes of at least 10 minutes, preferably spread throughout the week.
• Additional health benefits are provided by increasing up Io 5 hours (300 minutes) a week of
moderate-intensity aerobic exercise, or 2 hours and 30 minutes a week of vigorous-intensity ex
ercise. or an equivalent combination of both.
• Adults should also do muscle-strengthening activities that involve all major muscle groups per
formed on 2 or more days per week.
Older Adults (aged 65 and older)

• Older adults should follow the adult guidelines. If this is not possible due to limiting chronic condi
tions. older adults should be as physically active as their abilities allow They should avoid inactiv
ity. Older adults should do exercises that maintain or improve balance if they are at nsk of faNmg.
• For all individuals, some activity is better than none. Exercise is safe for almost everyone, and the
health benefits of exercise far outweigh the risks. People without diagnosed chronic conditions (such
as diabetes, heart disease, or osteoarthritis》and who do not have symptoms (e.g., chest pain or
pressure, dizziness, or joint pain) do not need to consult with a health care provider about exercise.
Adults With Disabilities

• Follow the adult guidelines.
• If this is not possible, these persons should be as physical〜 active as their abilities allow. They
should avoid inactivity.
IMM Slates Deporlment of Health and Human ServtOM 2008 •
• lb promote functional indqjendence in older

adults Exercise prescription
• To improve cardiorespfratory, metabolic, and
musculoskeletal fitness
Alterations to Address
There are many other possible goals for exercise
Individual Needs
and exercise* training The specifics of an exercise The definition of cancer survivor varies according to
prescription should be established according to the the source. The National Cancer Institute defines a
person、baseline health and fitness status as well cancer survivor as anyone who has had a diagnosis
as the personas goals. For example, the exercise of cancer; the term is used for the remainder of the
prescription and levels of supervision appropriate personrs life.6 This definiticxi is useful for many
for a young, healthy, fit 18-year-old with a goal to purposes, but when prescribing exercise for this
run competitively at the collegiate level would be population, it may be useful to distinguish between
quite different from the exercise prescription for cancer patients who are currently receiving treat
an overweight, sedentary 70-year-old who wishes ment and those who have completed treatment.
to return to playing singles tennis after 45 years of The US. DHHS guidelines to avoid inactivity to
sedentary living. improve health and reduce the burden of chronic
diseases1 is likely excellent advice for the cancer of aerobic endurance and preventing long-term
survivor, even during treatment. But dearly, more cardiotoxicities might be the primary focus of an
specifics are needed than merely to avoid inactivity. exercise program during and after cancer treat
Further, appropriate exercise prescriptive advice ment. For an older person with multiple health
likely varies across the cancer experience (e.g., problem*, maintaining functional mobility in order
during versus posttreatment). to live independently might be the focus. The fact
The first published guidance for exercise among that cancer strikes people of many ages and such
cancer survivors came fn>m the American Cancer a broad variety of health and fitness backgrounds
Society (ACS) in 2003/ This guidance differs some makes creating exerdse prescriptions that will be
what from the ACS guidance for cancer preiêntion safe, effective, and enjoyable for each survivor
presented earlier in this chapter. Briefly, the guid* challenging. The programming should take the
ance is for cancer survivors to continue normal daily following into account
activities as much as possible throughout treatment,
• Prior history of exercisftr
and to return to the recommenda tions for cancer
prev ention (presented earlier) as soon as it is safe to
• What the person is physically capable of
doing while undergoing and recovering from
do so, even while undergoing adjuvant treatments
treatment
such as chemotherapy and radiation. However, as
• Any physical problems or limits resultant to
noted earlier and in chapter 2, numerous adverse
treatment
effects associated with a cancer diagnosis, surgery,
and treatment might interfere with the ability to The ACS recommends that survivors consult
be regularly physically active, particulariy during with their physicians to ensure that the exercise
active treatment. The published ACS guidelines program will not interfere with treatment efficacy.
and advice an the ACS website (www.cancer.org) Unfortunately, there is very bttle empirical evidence
outline many of the ways cancer treatment can alter regarding what specific effects exercise may have
what would be appropriate and safe in terms of on treatment efficacy. As a result, physicians are
exercise programming. likely to base their advice on personal opinion and
Historically, physicians have advised those with clinical experience, as well as their primary aim of
any chronic illness (including cancer) to rest, take protecting the patient from any possible stressers
it easy, and reduce exercise. This is still advisable beyond cancer treatment
if movement causes severe pain, rapid heart rate, In June 2009, the American College of Sports
or shortntfjw of breath. However, it is increasingly Medicine convened j roundtable to develop the
recognized that exercise is not only safe and pos first-ever ACSM guidance for exercise testing and
sible during and after cancer treatment, but also prescription specifically for cancer survivors. The
can improve physical functioning and quality of expert panel conclusions are outlined in the two
life.•- * Further, the risks associated with physical sidebars on pages 92-95. The process of develop-
inactivity are considerable, including loss of func ing these guidelines started with a review of the
tion, strength, and range of motion, as well as scientific peer-reviewed literature, to discern both
negative psychosocial outcomes. Regular exerdse is the safety and effectiveness of exercise and exercise
increasingly recognized as an effective way to coun draining among survivors during and posttreat-
teract the negative effects of cancer treatment (e.g., ment. This evidence is reviewed in chapter 4 and
lymphedema, weight gain, fatigue, loss of physical briefly reiterated in the next section of this chap
functionV w Some clinical cancer treatment teams ter. Starting with the backdrop of the guidelines
urge their patients to keep moving and be active reviewed earlier, the panel decided to adopt much
even during treatment. of the existing recommendations from both the
As with the general population, the goals of an ACSM/AHA and the U.S. DHHS，particularly these
exercise program for someone undergoing cancer two words: avoid inactivity.
treatment will vary according to the person's predi- The panel generally recommends that survivors
agnosis general health history, fitness and activity follow the age-appropriate ACSM/AHA, U.S.
levels prior to diagnosis, and fitness and activity DHHS guidelines for aerobic activity, strength
goals. For a young athletic person, avoiding loss training, balance exercises, and flexibility acthities.
The ACSM guidelines for exercise prescription for of each of these recommendations. Later in this
cancer survivors and the recommended adapta chapter we review the many risks to survivors of
tions to the US. DHHS physical activity guidelines exercise and how these might result in the need
are presented in the two sidebars on pages 92-95. for an altered exercise prescription. In the next
Numerous adverse effects of cancer treatment will section, however, we summarize both the risks
affect the extent to which survivors will be able and benefits of exercise training to the cancer
to adhere to this guidance as well as the safety survivor.
Exercise Prescription for Cancer Survivors

This sidebar is pertinent to survivors of the following types of cancer: Breast, prostate, colon, adult
hematologc (no HSCT), adult HSCT. and gynecologic.
Objectives and goals of exercise prescription

1 To regain and improve physical function, aerobic capacity, strength, and flexibility.
2. To improve body image and quality of life.
3. Io improve body composition.
4. 76 improve cardiorespiratory, endocrine, neurological, muscular, cognitive, and psychosocial out
comes.
5. Potentially to reduce or delay recurrence or a second primary cancer.
6. Io improve the ability to physically and psychologically withstand the ongoing anxiety regarding
recurrence or a second primary cancer.
7. To reduce, attenuate, and prevent long-term and late effects of cancer treatment.
8. To improve the physiologic and psychological ability to withstand any current or future cancer
treatments.
General contraindications for starting an exercise program common across all

cancer sites
Allow adequate time to heal after surgery. The number of weeks required tor surgical recovery
may be as high as 8. Do not exercise individuals who are experiencing extreme fatigue, anemia,
or ataxia. Follow ACSM Guidelines for exercise prescription with regard to cardiovascular and
pulmonary contraindications tor starting an exercise program. However, the potential for an adverse
cardiopulmonary event might be higher among cancer survivors than age*matched comparisons
given the toxicity of radiotherapy and chemotherapy and long-term/late effects of cancer surgery.
Cancer-specific contraindications for starting an exercise program

• Breast： Women with immediate arm or shoulder problems secondary to breast cancer treatment
should seek medical care to resolve those issues prior to exercise training with the upper body.
• Prostate: None
• Colon: Physician permission recommended for patients with an ostomy prior to participation in
contact sports (risk of blow》and weight training (risk of hernia).
• Adult hematologic (no HSCT): None
• Adult HSCT: None
• Gynecologic: Women with swelling or inflammation in the abdomen, groin, or lower extremity
should seek medical care to resolve these issues prior to exercise training with the lower body.
Exerase Prescription for Cancer Survivors (continued)
Cancer*specific reasons for stopping an exercise program.

Note： General ACSM guidelines for stopping exercise remain in place for this population.
• Breast: Changes in arm/shoulder symptoms or swelling should result in reductions or avoidance

of upper body exercise until after appropriate medical evaluation and treatment resolves the issue.
• Prostate: None
• Colon: Hernia, ostomy-related systemic infection.
• Gynecologic: Changes in sweNing or inflammation of the abdomen, groin, or lower extremities
should result in reductions or avoidance of lower body exercise until after appropriate medical
evaluation and treatment resolves the issue.
General injury risk issues in common across cancer sites

Patients with bone metastases may need to alter their exercise program with regard to intensity,
duration, and mode given increased risk for skeletal fractures. Infection risk is higher for patients
who are currently undergoing chemotherapy or radiation treatment or have compromised immune
function after treatment. Care should be taken lo reduce infection risk in fitness centers frequented
by cancer survivors. Patients with known metastatic disease to the bone will require modifications
and increased supervision to avoid fractures. Patients with cardiac conditions (secondary to cancer
or not) will require modifications and may require increased supervision for safety.
Cancer-specific risk of injury, emergency procedures

• Breast： The arms and shoulders should be exercised, but proactive injury prevention approaches
are encouraged, given the high incidence of arm and shoulder morbidity in breast cancer survi
vors. Women with lymphedema should wear a well-fitting compression garment during exercise.
Be aware of risk for fracture among those treated with hormonal therapy, a diagnosis of osteopo*
rosis, or bony metastases.
• Prostate: Be aware of risk for fracture among patients treated with ADT. a diagnosis of osteopo*
rosis, or bony metastases.
• Colon: Advisable to avoid excessive intra*abdominal pressures for patients with ostomies.
• Adult hematologic (no HSCT): Multiple myeloma patients should be treated as if they are osteo
porotic.
• Gynecologic: The lower body should be exercised, but proactive injury prevention approaches are
encouraged, given the potential for lower extremity swelling or inflammation in this population.
Women with lymphedema should wear a well-fittng compression garment during exercise. Be
aware of risk for fractures among those treated with hormonal therapies, with diagnosed osteo
porosis. or with bony metastases
HSCT = hematopoietic stem cell transplantation.
93
Review of U.S. DHHS Exercise Guidelines (PAGs) for
Americans and Alterations Needed for Cancer Survivors
This sidebar is pertinent to survivors of the following types of cancer: Breast, prostate, colon, adult
hematologic (no HSCT), adult HSCT. and gynecologic.
General statement
Avoid inactivity; return to normal daily activities as quickly as possible after surgery. Continue normal
daily activities and exercise as much as possible during and after nonsurgical treatments. Individuals
with known metastatic bone disease will require modifications to avoid fractures. Individuals with
cardiac conditions (secondary to cancer or not) may require modifications and may require greater
supervision tor safety.
Aerobic exercise training (volume, intensity, progression)

• Breast: Recommendations are the same as age-appropriate guidelines from the R^Gs for Ameri
cans.
• Prostate: Recommendations are the same as age-appropriate guidelines from the PAGs tor
Americans.
• Colon: Recommendations are the same as age-appropriate guidelines from the RAGs tor Ameri
cans.
• Adult hematologic (no HSCT): Recommendations are the same as age-appropriate guidelines
from the RAGs for Americans.
• Adult HSCT: Okay to exercise every day. lighter intensity and lower progression of intensity rec-
ommerKted.
• Gynecologic: Recom mendations are the same as age-appropriate guidelines from the PAGs for
Americans. Morbidly obese women may require additional supervision and altered programming.
Cancer site-specific comments on aerobic exercise training prescriptions

• Breast： Be aware of fracture risk
• Prostate: Be aware of increased potential for fracture.
• Colon: Physician permission recommended for patients with an ostomy prior to participation in
contact sports (risk o< Mow).
• Adult HSCT: Care should be taken to avoid over-training given immune eflects of vigorous exer-
cise. /
• Gynecologic: If peripheral neuropathy is present, a stationary bike might be preferable over
weight-bearing exercise.
Resistance training (volume, intensity, progression)

• Breast： Altered recommendations. See betow.
• Prostate: Recommendations same as age-appropriate RAGs.
• Colon: Altered recommendations. See below.
• Adult hematologic (no HSCT): Recommendations same as age-appropriate R〜Gs.
• Adult HSCT: Recommendations same as age-appropriate R^Gs.
• Gynecologic: Altered recommendations. See below.
Review of U.S. DHHS Exercise Guidelines (continued)
Cancer site-specific comments on resistance training prescription

• Breast： Start with a supervised program of at least 16 sessions and very low resistance; progress
resistance at small increments. No upper limit on the amount of weight to which survivors can
progress. Watch for arm and shoulder symptoms, including lymphedema, and reduce resistance
or stop specific exercises according to symptom response. " a break is taken, back off the level
of resistance by 2 weeks' worth for every week of no exercise (e.g.. a 2-week exercise vacation =
back off to resistance used 4 weeks ago). Be aware of risk tor fracture in this populaton.
• Prostate: Add pelvic floor exercises for those who undergo radical prostatectomy. Be aware of risk
for fracture.
• Colon: Recommendations same as age-appropriate PAGs. For patients with a stoma, start with
low resistance and progress resistance slowly to avoid herniation at the stoma.
• Adult HSCT: Resistance training might be more important than aerobic exerase in bone marrow
transplant patients.
• Gynecologic: There is no data on the safety of resistance training in women with lower limb lymph
edema secondary to gynecologic cancer. This condition is very complex to manage. It may not be
possible to extrapolate from the findings on upper limb lymphedema. Proceed with caution if the
patient has had lymph node removal or radiation Io lymph nodes in the groin.
Flexibility training (volume, intensity, progression)

• Breast* Recommendations are the same as age-appropriate PAGs for Americans.
• Prostate: Recommendations are the same as age-appropriate PAGs tor Americans.
• Colon: Recommendations same as-age appropriate R八Gs. with care to avoid excessive intra-
abdominal pressure for patients with ostomies.
• Adult hematologic (no HSCT): Recommendations are the same as age-appropriate R久Gs for
Americans.
• Adult HSCT: Recommendations are the same as age-appropriate PAGs for Americans.
• Gynecologic: Recommendations are the same as age-appropriate F職Gs for Americans.
Exercises with special considerations (e.g., yoga，organized sports, pilates)

• Breast: Vbga appears safe as long as arm and shoulder morbidities are taken into consideration.
Dragon boat ra田ng not empirically tested, but the volume of participants provides face validity of
safety tor this activity. No evidence on organized sport or pilates.
• Prostate: Research gap.
• Colon: If an ostomy is present, modifications will be needed tor swimming or contact sports. Re
search gap
• Adult hematologic (no HSCT): Research gap.
• Adult HSCT: Research gap.
• Gynecologic: Research gap.
HSCT = hematopoietic stem cell transplantation.
Adaptod. by parnMMton. ftom K.H. Schmcz al., 2010. Amencan College of Spom Medcvw roundtable on guKMin_ tor cmvw turw>
vors.* Medtctne and Sconce n Sports and Exetcta^ 42(7): 14O&-26
95
Benefits and Risks of ment for breast cancer, including improvements in

aerobic fitness and strength, as well as flexibility,
Exercise and Exercise physical function, and safety with regard to risk for
lymphedema among survnvors who have completed
Training treatment. Studies of prostate cancer survivors have
shown evidence of improvements in aerobic fitness,
Historically, cancer patients were told to rest and strength, body size and composition, quality of life,
take it easy. This advice continues in many places energy level, and physical function, with evidence
even today as a result of the fear that excessive activ levels of A or B for all of these categories. From
ity will make a patient who is already not well feel there, the number of studies decreases considerably,
even worse. Given that cancer treatment can result resulting in few outcomes that provide sufficient
in fragile physiological and psychological states, it evidence to warrant any conclusion of benefit. For
is useful to establish, first, that it is safe for survivors example, only four intervention studies have been
to be physically active. published to date that have examined the benefits
A review of the peer-reviewed scientific literature of exercise among adults with hematological malig
on exercise interventions in cancer survivors during nancies who are not treated with hematopoietic
and after cancer treatment for multiple cancer sites, stem cell transplantation (HSCiy
including breast, colon, prostate，hematological, and As noted earlier, many factors converge to deter
gynecological cancers, reveals that exercise is quite mine the risks of specific of exercise for any
safe, with few adverse events reported in the 4B given survivor. The next section reviews some of
studies evaluated.* In many cases, the adverse events the factors that fitness professionals should con
were not unique to cancer survivors. For example, sider when developing an individualized exercise
in one study, a few breast cancer survivors partici prescription for a cancer survivor.
pating in a walking intervention developed plantar
fasciitis?1 In a study of prostate cancer survivors,
an older man experienced a myocardial infarction
15 minutes after completing an exercise session.12
Exercise Prescripti 에
These events may have occurred in these partici
pants regardless of any cancer history. The overall
InA6B • lizati 매
conclusion of the review panel was that a wide Cancer treatment results in changes that must be
variety of exercise programs are well tolcraled, with considered when individualizing the exercise pre
few adverse effects, even during severe CMwer treat scription to a specific survivor. Chapter 2 covered
ments such as stem cell transplantation.8 Fears that these changes in depth. This section considers those
cancer survivors arc too fragile to exercise during changes in the context of how they alter exercise
treatment may be unfounded? In fact, exercise has prescription. As an overview, it might be helpful
been shown to be beneficial to cancer survivors to think about all of the body systems required to
during and after treatment as re*4cwcd next. exercise, and then compare those systems to the
The benefits of exercise training during and systems af^cted by cancer treatments. We need the
after cancer treatment were reviewed in greater musculoskeletal, nervous, cardiovascular, respira
depth in chapter 4. Table 4.1 on page 51 presents tory, meUbolic, and endocrine hormonal systems to
the level，of evidence for specific outcomes within perform exercise. The capacity of each of these sys
cancer survivorship populations as noted by the tems can be altered by the various treatments used
rec베ly completed guidelines panel from ACSM- to treat cancer. Other body systems are also altered
To summarize, considerably more research has been as a result of exercise training, including cell signal
published on breast cancer survivors than on any ing pathways, the immune system, and reproductive
other diagnostic category among survivors. As a hormonal systems. Exercise prescriptions need to
result, sufficient studies exist to warrant the stron be adapted to the current condition, abilities, and
gest possible evidence rating (evidence level A). interests of each individual survivor. The safety of
Multiple randomized controlled trials demonstrate the survivor must be foremost in the fitness profes-
benefits of exercise both during and following treat sional’s mind when developing a program.
tive heart failure, kidney disease, or any other

diseases or events associated with the cardio
Take-Home Message vascular system?
The following physiological sys • Hematological parameters and immune func-
tems are affected by exercise: tion: Does thi$ person have anemia or tvducvd
• Muscles, tendons, ligaments blood cell counts that would place him or her
at increased risk of infection?
• Bones
• Respiratory health: Does this person have
• Nervous system: Cognition, memory, asthma? Chronic obstmetive pulmonary dis
sensory and motor systems
ease? Abnormal respiratory function for any
• Cardiovascular system other reaMMi?
• Respiratory system • Musculoskeletal health: Do any body parts or
• Hormones (endocrine and metabolic joints lack normal functional range of motion,
systems) strength, or coordination?
When developing individualized exercise • Nervous system health: Does this person have
prescriptions for the cancer survivor, the fit a normal walking gait? Any loss of sensation,
pain, or altervd svnâtion in the feet, hands,
ness professional must know the effects of
or elsewhere?
the cancer and its treatments on these sys
tems as we" as the relevant medical history • Cognitive health: Does this person have
of these body systems. Only then can risks normal and memory? is there any
obvious impairment in understanding and
be minimized and benefits maximized.
Following directions or remembering what
w顧、discussed at a prior meeting?
• Metabolic and hormonal health: Does this
person have diabetes, metabolic syndrome,
Current Medical Condition obesity, thyroid disease, or any other disorder
Prior to prescribing exercise for a cancer survivor, associated witi、hormones?
the fitness professional must know how the cancer

diagnosis, treatment, or both, have affected each of
the systems required for and affected bv exercise.
Take-Home Message
During active treatment, it is appropriate, though
Those who have a cancer di
not always necessary, to ask for physician clear
agnosis are likely to be older
ance prior to prescribing exercise for a survivor.
adults, a population likely Io
A request for physician clearance should include
have other chronic health con
details of the exercise mode, frequency, intensity,
ditions as well, such as orthopedk: issues,
and session duration Figure 6.1 is a note survivors
cardiopulmonary disease, diabetes, and
can use U)reque■會 written clearance from their phy obesity. A fitness professional prescribing
sicians during active cancer treatment. Survivors
exercise for a cancer survivor needs to con
who have completed cancer treatment can use an
sider the person's full medical history and
adapted version of this form. The note can also be current condition, not just the person's can
altwed to address the unique needs of clients. cer history.
Whether a fitness professional chooses to get
physician's clearance or not, it is important to know
the current medical condition of the client with
regard to the following: Time Since Diagnosis
• Bone health: Is there any reason to think that Those diagnosed with cancer and receiving treat
this person is at risk for bone fractures? ment experience a variety of physiological and
• Cardiovascular health: Has this person ever psychological changes over time. Those who have
been diagnosed with hypertension, conges recently been diagnosed and are awaiting treatment
Figure 6.1 Physician's Permission Form
Dear Dr. :
I am interested in participating in an exercise program during my active cancer treatment. I would like you to
know what I plan to do and ask you to sign below if you believe that my current medical condition will allow me
to participate in this program without compromising my treatment outcomes or general health. Thank you for
reviewing this. I am working with a fitness professional who has obtained a certification from the American
College of Sports Medicine (ACSM Certified Cancer Exercise Trainer) to work with cancer survivors. My
fitness trainer has asked me to have you review this program and obtain your written permission.
Exercise mode:
(Examples: Walking program, weight training, tennis lessons, yoga, Pilates, dragon boat raang》
Frequency of activity:
(Examples: Once weekly, three times weekly, daily)
Intensity of activity: _______________________

(Examples: mikl intensity―I will not sweat doing this activity; moderate intensity—I will sweat but I will
be able to converse while participating; vigorous intensrty—I will sweat and breathe hard while doing this
activity)
Duration of each activity session: 齡 가
(Examples: 20 minutes. 30 minutes, 60 minutes, 2 hours)
Setting in which this activity will occur: \스스'
Level of supervision:
For physician signature only:
■， ________________________________ . have reviewed the above proposed program and approve

of my pfUent participating in the above-described program
while undergoing chemotherapy, radiation therapy, or other active cancer treatments. I recommend the
follow adaptations to the program above for my patient's safety.
Check one:
No adaptations from what is stated above
Adaptations as follows:
Print Name/Signature/Date
From ACSM, 2012. ACSM'a gMfe to exerctse and cancer survivorstup (Champaign. Il_ Hunan Kme*cs).
Diagnosis
C«nc«c control categories
Prevention -* Delecbon -* Treatment -* Treatment -► Recovery -♦ Disease -► Palliation -► Survival

prvparatloo •■•ctlv，n_ss and prevention
and and rehabiktabon and
ᄆ copwig coping health promotion
PrMcm«ning Screening P離trMtment Treatmenf Surwonhip End of _•

■ i
Prediagnosis Postdiagnosis
Canc*r-r»tated time parioda
Figure 6.2 Physical activity and cancer control framework.

R«pnn_d from S_r*_ts In Oncology Nur，，산 Vol 23(4). K.S- Co«n«ya an4CM FrledenMcfi. KlMty and cancer oof«ol.* pg« M2-2S2,
copyngM 200Z •상 pernwaion town Elaeâr
are different, physically and psychologically, hum be the most physiologically vulnerable. Although
cancer survivors who are 1, 5, and 15 years out treatments can be spread out over several years
from the end of their curative treatment. Those who for some types o£ cancer, others may take only a
have had multiple diagnoses (e.g., second cancer、 few weeks or months. Therefore, even if the client
recurrences) differ from those uilh a single cancer reports being done with treatment, it is a good idea
diagnosis. to ask whether any additional follow-up treatment
This continuum of the cancer experience is is planned. It is also a good idea to inquire about any
depicted in the exercise and cancer control frame lymphatic, neurological, or immune system factors
work in figure 6.2. Jhe goal of this framework is to that may require further evaluation by medical or
distinguish among the needs and abilities of sur allied health professionals before participation in
vivors based on where they are in the continuum physical activity.
(e.g., currently undergoing treatment, recently Some forms of treatment may last five or more
completed treatment, or in long-term survivorship years. The most common example is the hormonal
and exercising to promote general health and pre therapies provided orally to women with repro
vent recumnKe). The exercise prescription must ductive cancers and to men with prostate cancer.
take into account the time since diagnosis and the Technically, these medications are considered
appropriate goals for that time frame. Goals of adju\rant treatment for cancer. However, when most
exercise prescriptions range from improving treat clients report being finished with treatment, they are
ment effectiveness and coping with the side effects referring to being finished with appointments that
of treatment (during active treatment) to preventing require going to a facility for cancer treatments, such
di*»easc and promoting health (in the years after the as radiation therapy or intrax*mous chemotherapy.
end of active treatment). Cancer survivors who are undergoing chemo
therapy, radiation therapy, or both, may have
rvducud immune function that may render exer
On or Off Adjuvant Treatment cise in a public facitity hazardous, because they
and Timing of Current are susceptible to developing systemic infections
Treatment with fevers. Knowing whether a client is currently
immune compromised is crucial. Fitness profession
The goals of exercise and the ability of cancer als should ask clients whether they were told that
survivors to participate in exercise will change they are susceptible to infections as a result of their
throughout the cancer experience. Therefore, under current treatment regimens.
standing where the client is with regard to the treat Further, energy levels will be reduced during
ment trajectory is crucial. Those who have recently chemotherapy and radiation treatments. These
undergone or are currently undergoing systemic treatments work by killing rapidly dividing cells.
treatments (e.g., radiation and chemotherapy) will Although treatments are increasingly targeted at
100 ACSM’s Guide to Exercise and Cancer Survivorship www.acsm.or 모
the tumor cells themselves, it is still common for spreading to other parts of the body via lymphatic
both chemotherapy and radiation therapy to result vessels. Brvast cancer patients, for example, com
in systemic alterations in the types of healthy body monly have at least a few lymph nodes removed to
cells that turn over rapidIyz such as those that make check for cancer cells in that lymphatic tissue. This
up skin« hair, nails, the inside of the mouth, jnd the is a way to determine whether the cancer cells have
lining of the digestive tract. Also, these treatments migrated to distant parts of the body, such as the
can result in an increase in the number of cells that lungs, bone, or liver. Some cancer pahents undergo
respond to inflammation (i.e., cytokines). Cytokines additional reconstructive surgical pnKedures. The
also increase when we are sick, such as when we most conunon reconstructive surgery in cancer
have the flu, and explain, in part, the achy feeling patients is breast reconstruction. Reconstructive or
that comes with being sick. Cancer patients with cosmetic surgery is also associated with other cancer
increased cytokine levels in their blood may feel types, such as testicular cancer (testicular implants)
achy and sick all the time. and head and neck cancers (facial plastic surgrry to
The side effects of both chemotherapy and radia recreate altered facial features, or improve speech
tion treatments are the result of the treatments on or swallowing function, or both).
nontumor cells that turn over rapidly. One common Regardless of whether the purpose of the surgery
side effect is a reduced energy level (i.e.# cancer- is curative or roeonstructive/cosmetic, musculosk
related fatigue). These side effects can be short eletal tissue is generally severed and altered as a
lived, going away as soon as the treatment is over, result. This is a traumatic event for the musculature
or persistent, lasting for years. For example, those and sgA tissue that requires healing time. It may also
who undergo high-dose chemotherapy in assoda- result in scarring and a change in the function in the
tion with a stem cell transplant can have reduced soft tissue that has been cut through and sometimes
immune parameters and increased inflammatory altered as a result of the procedures.
markers for several years after completing treat The sidebar Example of Effects of Surgery on
ment. Fitness professionals should also be aware Exercise Prescription: Breast Reconstruction With
that cancer treatment may accelerate functional Expanders discusses one type of cancer surgery
decline associated with aging, particulaily- in the and how it might affect the choice of upper-body
elderly. Exercise programming may need to be activities. This example illustrates the need to ask
adjusted accordingly. about the location of any cancer surgeries that
Fitness professionals should ask their clients have been performed for curative or reconstruc-
what treatments they are currently undergoing, hve purpoMKi, (plowing the medical guidelines
have undergone, and still need to complete, as well for returning to normal daily activities (and
as the timing of these treatments, to get an idea of exercise) fot the surgeries experienced by each
the extent to which the side effects of systemic treat client h important. (The American Cancer Society
ments are likely to be an issue. Also of note is the fact website is an outstanding source of information
that some treatments may cause skin discoloration, nn guidelines for exercise after cancer surgeries of
skin tightening, dryness, and ulcerations. Thus, the all kinds.) It could be useful to ask the client about
fitness professional should know of, and remind changes in sensation, function, strength, and range
the survivor to use, appropriate sun protection for of motion in the area where surgery was performed
outdoor exercise. prior to developing an individualized prescrip
tion or clearing the client for participation in an
Type and Recency of exercise program that assumes a particular level of
Surgical Procedures and ability.

Another relevant issue related to postsurgical
Presence of Implants guidelines for exercise prescription is the removal
Surgery for cancer might include both curative and of lymph nodes. This is done to investigate whether
cosmetic or reconstructive procedures. The curative the cancer has spread to or through the lymph
surgeries arc intended to remwe the cancer cells and system, or because the cancer has been determined
immediate surrounding tissue. Sometimes lymph to have spread to or through the lymph system.
nodes are removed as well, to prevent cancer from When lymph nodes are removed, the portion of
Exercise Prescription and Programnung Adaptations 101
Example of Effects of Surgery on Exercise

Prescription: Breast Reconstruction With Expanders
Reconstructive surgery for breast cancer might include the use of expanders, which are temporary
implants that are surgically inserted under the pectoral muscles. Expanders are inserted flat, with
a port to allow gradual filling over one to three months. To increase the size of the expander, saline
is injected into it to gradual^ stretch the soft tissues, skin, and pectoral muscles to allow room for
the permanent implants (saline or siicone) that are intended to stay in place for decades. Some
expanders are left in place as the permanent implants.
While expanders are in place and tor four to six weeks after the final placement of the permanent
implants, physicians generally recommend that women avoid overhead lifting or any strenuous
exercise. The range of motion possible in the shoulder girdle is reduced, as might be expected
when the pectoral muscles are stretched from underneath. This would need to be considered when
choosing stretches, weight training exercises, yoga poses, or other activities that require a full range
of motion in the shoulder girdle.
Expanders are just one example of a common breast reconstruction surgery. Another involves
moving a small piece of muscle from the transverse abdominis or latissimus dorsi with fat from the
abdomen or back to recreate a breast from the woman’s own tissues. This surgery also would have
implications tor the safety of certain exercises, at least in the short term.
the body served by those lymph nodes is forever printable handouts that can be shared with cancer
altered with regard to its response to infection, survivors as well as information on ISrisk reduction
injury, inflammation, and trauma. Exercise training practices (www.hmphnetxwg).
needs to be approached in a rehabilitative manner,
rather than a training manner, for the affected Range of Meiion
body part. For example, after breast cancer surgery
As discussed earlier, cancer surgeries cut through
that includes the removal of lymph nodes from
soft tissues. This can result in scarring and altered
the armpit (called axillary node disseetkm), some
range at motion, particularly when the survivor
women find that a simple cut on a finger while gar
is encouraged to protect the area after treatment.
dening results m 着 systemic bacterial infection that
Further, radiation therapy can result in scarring and
requirvs antibiotics. This occurs because the removal
trauma to soft tissues as well and may alter range
of lymph nodes disrupts the usual communica tion
of motion. Prior to developing an individualized
through the lymph system that bacteria and cellubr
exercise prescription or cieanng a survivor for a
debris have entered the body. This can result in the
premade program that assumes some particular
development of a commcm persistent adverse effect
range of motion in any particular joint, fitness pro
called lymphedema.
fessional would do well to evaluate the personrs
Lymphedema is thought to occur in 17 to 42%
current range of motion. Methods for evaluating
of breast cancer survivorsJ4-1 b and approximately
range of motion prior to exercise prescription are
30% of patients who have lymph nodes removed for
reviewed in chapter 5.
melanoma or gynecological, bladder, and testicular
cancers.17-19 It is a chronic, incurable condition that
is increasingly difficult to manage as it progresses. Amputations
Therefore, fitness professionals working with cancer One possible outcome of a cancer surgery is amputa
survivors must understand this condition and how tion of a limb or part of a limb. The need for reha
best to prevent it. The best source of information bilitation following an amputation is obvious to the
about lymphedema is the National Lymphedema medical community to ensure a return to functional
Network website, which includes a number of mobility and activities of independent living. Most
cancer survivors with limb amputations undergo join a masters running club three months after
both physical therapy and occupational therapy tTvatmcnt. By contrast, a sedentary, overweight,
to regain basic functions to allow for self-care, the diabetic 40-year-old diagnosed with stage III colon
return to occupational activities, and independent cancer that requires extensive surgical resection, an
living. However, after that, they are on their own external ostomy (eg.，a bag outside the body that
for determining a personalized exercise prescription stores waste), and a long bout of chemotherapy
to regain full fitness and health. might need physical therapy just to return to
Clearly, the exercise prescription and program functional mobility and independent living prior
ming needs of those who experience amputation to beginning a basic walking and weight training
as part of cancer surgery are unique. However, program. The point is to evaluate survivors accord
because amputation is not a common outcome ing to their current abilities and prescribe appro
in cancer survivors, exercise adaptations for this priate exercise programming according to the
population are beyond the scope of this book. The findings. ,
ACSM offers a certification to prepare personal
trainers to work with people with disabilities. Hematological
Certified personal trainers and other allied health
professionals who plan to work with a cancer Considerations
survivorship population that includes a high pro Systemic cancer treatments such as chemotherapy
portion of amputees (such as those who have had and radiation kill rapidly dividing ceds, which may
sarcomas) are directed to materials specific to that include healthy cells as well as cancer cells. Because
population. blood cells are among those that divide rapidly,
blood cell counts are depicted during chemotherapy
Effects of Treatment on All and radiation therapy. This is important to consider
when prescribing exercise because red blood cells
Elements of Fitness carry oxygen, and because a low white blood cell
The elements of fitness include agility, speed, count (e.g., as a result of thrombocytopenia, leuco
coordination, flexibility, strength, and endurance. penia, or neutippenia) results in an increased risk
Before clearing a cancer surtivor for participation for systemic ififccticms with fever.
in a specific program or developing an individual In prnchbing exercise for cancer survivors, fit
ized exercise prescription for that person, the fitness ness professionals should know whether they are
professional must understand what the exercise currently undergoing or have recently undergone
program will require of the sunivor with regard to any treatments that would alter blood cell counts,
each of these elements, and whether the survivor is such as chemotherapy or radiation therapy. If so,
capable of participating in that component of exer* home exercise might be preferable to pre^gram-
cise. For example, if a specific mode of aerobic exer ming in public settings. Frequent hand washing
cise requires the ability to sustain an intensity and ensuring that exercise equipment is cleaned
of 7 to 9 METS, but the maximal aerobic capacity of often would be important as well. Fitness profes
the client is 8 METs, it would not be appropriate to sionals should also be mindful of the inverted
prescribe that particular mode of aerobic exercise. J-shaped relationship between exercise and
It is important to match the programming with the immune function: vigorous-intensity, prolonged
ability of the client. aerobic activity suppresses immune function.20
One particular challenge in working with the In contrast, those who are moderately physically
cancer survivorship population is the interaction active have better immune function than those
of aging with cancer. Cancer is more likely to ocxur who are inactive. Survivors who are immune
in older people. Also, those who are diagnosed compromised already should avoid high-intensity
with cancer seem to experience an acceleration of activity.
functional aging. However, a healthy, fit 70-year- A survivor who is fatigued during the weeks
old diagnosed with early-stage cancer that requires or months after completing chemotherapy, radia-
minimal surgery, no chemotherapy, and a short don therapy, or both, might be anemic or have
round of radiation therapy could be ready to reduced white blood cell counts. This would need
to be assessed by an oncology dinidan. A condi First, there is the potential for a hemia at the site
tion called cancer-rchted fatigue is distinct from of a stoma. This requires prescribing exercise that
anemia, and exercise is the leading nonpharmaco- works the muscles around the stoma without
logical intervention for it.w However, the first line overstraining them. Second, a stoma is a new
of treatment for the drop in energy level experi route through which infection can enter the body.
enced by most cancer survivors during adjuvant This requires attention to stoma cleanliness on the
therapies is to prescribe hematopoietic growth part of the survivor before, during, and after each
factors that stimulate the bone marrow to produce exercise session. Cancer survivors with ostomies
more blood cells. Erythropoietin is prescribed to should review appropriate cleaning procedures
improve cancer patients' ability to transport and for before, during, and after exercise sessions with
use oxygen and increase hematocrit and white their medical care te^ms prior to starting new
blood cell counts. One study suggests that aero programs.
bic exercise during chemotherapy may result in
the need for additional monitoring of the dosage
required for these blood product medications,
given that aerobic exercise training also increases
Acute and Chronic
red blood cell counts.3 Adverse Effects of
As noted in earUer sections, the advice is to indi
vidualize exercise prescriptions according to the Treatment
current needs and abilities of the cancer survivor.
A variety of symptoms and side effects occur as
a result of cancer treatments. Some are acute, or
Presence of a Central Line 7 short-lived, effects that dissipate soon after treat
or an Ostomy | ment ends, such as hair los®. Others are chronic,
such as peripheral neuropathy in the hands and
Survivors receiving intravenous chemotherapy
commonly have a catheter inserted just under the feet after treatment with one of several classes of
skin, usually just below the collarbone, so they don’t chemotherapy drugs called taxanes or platinum
have to go through a catheter insertion every time based drugs such cisplatin. Chapter 2 provides a
they come in for treatment. Ihese PIC lines (also comprehensivet，view of the common side effects
known by the brand name Port-a-Catheter) can be of cancer treatments. Fitness professionals adapt
damaged by overstretching the area where they ing exercise programs to meet the needs, goals,
are placed. Asking survivors who are currently and abilities of cancer survivors should know
undergoing chemotherapy whether they have an which treatments have been received, so they can
indwelling oithrtcr, a HC, or Port prior to designing ipok at chapter 2 or the American Cancer Society
an exercise program enables fitness professionals to website to determine what the common side
adapt the activities to avoid overstretching or strain effects are and which adverse effects might occur
ing the *rva of the indwelling catheter. There is m> later. They can then ask their clients what they are
evidence currently available to establish the safety currently experiencing and adapt their programs
of weight training with an indwelling catheter in accordingly-
the antecubital space (e.g., inner elbow). Therefore,
clients with PIC lines in the bicep or elbow area Exercise Risks Attributed
should prcKeed with caution when undertaking
weight training activities.
to Cancer
Some cancer survivors have a stoma, or opening In addition to learning about the side effects their
out of the digestive or urinary tract, that allows for clients may be currently experiencing, fitness pro
waste to be removed from the body after a surgery fessionals should know what treatments their clients
to remove cancerous tissue from the colon, rectum, are currently undergoing, given that exercise could
or urinary system. An ostomy bag is worn to col be riskier following particular types of cancer treat
lect bodily waste. This new hole coming out of the ment. For example, people with multiple myeloma
body creates two issues for exercise prescriptions. may be at risk for bone fractures at a variety of sites.
To avoid o\rerstressing their bones, these people Contraindications and

may want to avoid certain moders of exercise that
might result in falls or strain on the skeletal system
Knowing When to Refer
(e.g., tennis, plyometrics). Following are conditions to Medical Care
that may result from certain cancer treatments, Cancer can create a medical condition severe
which should be considered when planning exercise enough that any type of exercise would be inad
programming: visable. Thankfully, this u not a common scenario.
• Cardiac arrhythmias, myopathies, or heart Improvements in early screening and the detec
failure after some forms of chemotherapy and tion of cancer result in the majority of cases being
radiation to the chest wall diagnosed 신 early enough stages that exercise is
• Bone metastases due to disease progression feasible for most cancer survivors, including those
undergoing treatment.
• Decreased bone strength due to hormonal
Adverse effects of cancer treatment can also be
therapies
intense enough to create a medical condition that is
• Peripheral neuropathies due to some forms incompatible with just about any type of exercise.
of chemotherapy Again, thankfully, this occurs infrequently, and
• Muscle pain or arthralgia due to treatment when it does, it typically resolves within days or
with aromatase inhibitors weeks, or once treatment is complete. Therefore,
• Altered memory or ccxirdination due to che the majority of cancer survivors arc capable of par
motherapy, surgery, or radiation treatment ticipating in at least some form of exercise. Many
• Lymphedema after removal of lvmph nodes are capable of performing exercise at the levels
in the armpit cir groin rvcommcfKled by the U.S. DHHS for promoting
health and preventing disease in healthy adults or
The level of supervision should be increased for older adults.
people with these issues, bax，d on their particular None of the dozens of well-executed randomized
needs. Similarly, alterations in exercise program controlled exercise intervention trials conducted in
ming as a result of these issues will also need to cancer survivors during and after treatment con
be individualized. Folk^wing an? some examples： cluded that exercise is unsafe.* That said, these trials
• A person with cognitive impairment after che included volunteers and often recruited only a small
motherapy might not be the best candidate for proportion of the possible survivors who could have
learning a complicated weightlifting routine participated at any given cancer treatment center.
that requires excellent biomechanical form and Therefore, it is possible that the studies are biased
that the person has to remember from session because they examined the safety of exercise only
f to session. among those who were most capable of tolerating
• A person with severe sensory changes in his the programs prescribed.
hands after platinum-based chemgtherapy Cancer is not a disease to be taken lightly. It does
might be likely to drop dumbbells if he cannot cause significant physiological and psychological
sense where they are in his hands. challenges. Therefore, fitness professional work
• A survivor with bone metastases might prefer ing with cancer survivors must be aware of the
a recumbent stationary bike to equipment that signs and symptoms that indicate the need to dehy
requires balance and weight bearing, which starting an exercise program. Two items crucial for
might risk a Fall. discerning are whether the survivor is anemic or
• A person at risk for arrhythmia and heart immune compromised. These conditions are most
failure might need greater monitoring of heart likely to occur during chemotherapy* or radia由on
rate, dyspnea, and angina during exercise. therapy and are likely to clear up within weeks or
• Progressive weightlifting regimens should months after the end of these treatments.
start at very low weights and progress in very Survivors undergoing treatments that result
small increments for survivors with lymph in hcmatok)gical parameter changes should have
edema secondary to the removal of lymph written clearance from a physician before starting
nodes for cancer treatment. an exercise program. Further, survivors should be
asked whether they have normal blood cell counts

according to their physician after completing these ，선타 Take-Home Message
treatments. Finally, people who undergo hemato Cancer is a catchai term for
poietic stem cell transphnts receive high doses of more than 200 types of illness.
chemotherapy prior to transplant. White blcxxd cell It takes time and experience to
counts may take longer to recover from HSCT than understand all the signs and
from typical doses of chemotherapy. Some patients symptoms ind比ating that a cancer survivor
experience suppressed immune function for years needs to be referred to a health care pro
after HSCT. vider. Establishing a channel of communica
Finally, because cancer can recur and adverse tion with the clinicians who treat the cancer
effects of cancer tredtment can show up months can help to determine the specific issues to
and years after completing therapy, fitness pro watch for. particularly in patients currentty
fessionals must know the signs that indicate the undergoing treatment.
need for a referral to a health care professional
for further evaluation or treatment. One caveat
to presenting this list of signs is that many cancer
suivivors live in fear of recurrence and take every
symptom as a sign that the cancer has returned. In
Setting Goals
fact, some equate muscle soreness with the pain Each cancer survivor will have his or her own
that is a sign of cancer having metastasized to goals, and those goals will shift during the cancer
the bone. Therefore, a delicate balance is required experience (e.g., during versus after treatment). The
between taking symptoms seriously and recom exercise prescriphan should match those goals. A
mending that a survivor seek medical attention, specific goal (e.g., to climb Mount Rainier someday)
and adding to the ongoing fear that the smallest can help the fitness professional design a program
symptom is a sign that the cancer has returned to prepare the person physiologically to achieve that
A key indication that medical attention is war goal. However, many survivors have very general
ranted is when the signs listed in the sidebar Signs goals, such as wanting to feel better, look better, or
Indicating the Need for Referral to a Health Care live longer. In this case, the exercise prescription
Provider cannot be obviously explained as result can build from whatever is currently possible to
ing from some other cause. Far example, a survi meeting the general guidelines of the U.S. DHHS,
vor who develops a fever without any obvious the ACSM/AHA. or the 八
source of infection (e^ upper respiratory symp One thing to watch for carefully in this popu
toms, bladder symptoms) should seek medical lation is increasing fatigue and symptoms with
attention. overtraining To avetid this, the fitness profrssUonal
Signs Indicating the Need for Referral to a Health Care Provider

• Unusual tiredness or unusual weakness • Flare of lymphedema symptoms
• Fever or infection • Change in the appearance or feel of the can
• Difficulty maintaining weight, severe dianhea. cer site
or vomiting • Lump in the breast or groin, change in skin
• Leg pain or cramps, unusual joint pain or color or texture
bruising • Significant changes in coordination, vision,
• Sudden onset of nausea during exercise hearing
• Irregular heartbeat, palpitations, or chest pain

Based on ww«.ncpad.Of^(lsdtNMy/lact sf»et.php?sr)eet= 19S&secaon= 1465.
should check in with the client regularly between It is well established that prolonged vigorous
exercise sessions to find out if any changes in side exercise may decrease immune system effective
effects are occurring, including increasing fatigue ness and increase the risk of infection23 as well as
or reduced energy levels. If there is an increase in injury.24 Rtness professionals working with cancer
fatigue or a worsening of any acute or persistent survivors_«especially those undergoing active treat
negative effects of treatment, the exercise dose ments―should monitor for signs of overtraining,
should be reduced by modifying intensity, session including the following:
duration, session frequency, or all of these things.
• Increased fatigue
Decreasing the intensity and duration rather than
the frequency of exercise, however, will promote • Insomnia
continued exercise compliance. The sidebar Tips • Increased irntabilih'
From the American Cancer Society: When You Are • Increased heart rate at a given exercise inten
Too Tired to Exercise—Fatigue and Cancer pro sity
vides tips on how to maintain an exercise program
• Poor exercise performance
during active cancer treatment, given the common
• Voight loss
challenge of increased fatigue. Monitoring fatigue
levels with a standardized survey is a good way • Psychological effects of overtraining (e.g.,
to determine whether fatigue levels are changing. depression, loss of enthusiasm)
Multiple surveys are available for this purpose. • Excessive muscle soreness
Figure 6.3 is one such survey.2 • Injury
In addition, simply asking tired are you
• Headaches, dehydration, or both
today on a scale of 0 to 10?" and whether there are
any particular reasons for increased fatigue at the If any of these occur, exercise dose should be
beginning of each session might be sufficient for reduced immediately. If the signs of overtrain
such monitoring. A recent review noted that on a ing do not reverse themselves after reducing the
scale of 0 to 10 (0 = no fatigue, 10 = worst fatigue exercise dose, the client should seek a medical
imaginable), a score of 1 to 3 is considered mild, 4 valuation and stop exercising until that ev alua
to 6 is maderate, and 7 to lpis severe.* tion is complete.
Tips From the American Cancer Society: When

You Are Too Tired to Exercise—Fatigue and Cancer
Many people notice a loss of energy during cancer treatment.
• During chemotherapy and radiation, the majority of patients have fatigue.
• Fatigue may be severe and limit activity.
• Inactivity leads to muscle wasting and loss of function.
An aerobic training program can help break this cycle.
• Regular exercise has been linked to reduced fatigue.
• It is also linked to being able to do normal daily activities without maior limitations.
• An aerobic exercise program can be prescribed as treatment for fatigue in cancer survivors during
and after treatment.
• Talk with your doctor about this.
Baaed on Amancan Cancer Soaety A' ■禮•■:，，w cwic«r.cf(>^«Mtrn»nVS<xv«vorvhipOurmgBndAMarTiMlrn»nVSlaymoActiv»lJft|f«ical-aclMty-

antHfw-canoMiMmni
Figure 6.3 Fatigue Symptom Inventory
For each of the following, circle the one number that best indicates how that item applies to you.
1. Rate your level of fatigue on the day you felt most fatigued during the past week:
0 1 2 3 4 5 6 7 8 9 10
Not at all As fatigued as
fatigued I could be
2. Rate your level of fatigue on the day you felt least fatigued during the past week：
0 2 3 4 5 6 7 8 9 10
fatigued I could be
3. Rate your level of fatigue on the average during the past week:
0 1 2 3 4 5 6 10
fatigued I could be
4. Rate your level of fatigue nght now:
0 1 2 3 10
fatigued ♦ could be
5. Rate how much, in the past week, fatigue interfered with your general level of activity:
0 3 4 5 6 7 8 9 10
No Extreme
mterlerence interference
6. Rate how much, in the past week, fatigue interfered with your ability to bathe and dress yourself:
1 2 3 4 5 6 7 8 9
No Extreme
interference interference
7. Rate how much, in the past week, fatigue interfered with your normal work activity (includes both
work outside the home and housework):
0 2 3 4 5 6 7 8 9 10
No Extreme
8. Rate how much in the past week, fatigue interfered with your ability to concentrate:
0 2 3 4 5 6 7 8 9
No Extreme
(continued)
107
Figure 6.3 Fatigue Symptom Inventory (continued)
9. Rate how much, in the past week, fatigue interfered with your relations with other people:
0 1 2 3 4 5 6 7 8 9 10
No Extreme
10. Rate how much in the past week, fatigue interfered with your enjoyment of life：
012345678 9 10
No Extreme
11. Rate how much, in the past week, fatigue interfered wrth your mood：
012345678 9 10
No Extreme
12. Indicate how many days, in the past week, you felt fatigued tor any part of the day:
0 1 2/ 34567
Days Days
13. Rate how much of the day. on average, you felt fatigued in the past week:
0 1 2 3 4 5 6 7 8 9 10
None of The entire
The day day
14. Indicate which of the following best describes the daily pattern of your fatigue in the past week:
1 2 Z、3 4
Not at all Worse in Worse in Worse in No consistent daily
fatigued the morning the afternoon the evening pattern of fatigue
Hom ACSM. 2012 ACSM'a lo 0j_*c 離• and c^ncf turvtvontup (Champaign. IL Human KmMcs>. W«h kind pemB«*on tram Sponger
Sc»ence*Busines5 Meoa: Ouatry at Life Aesaa/cA. -*Measufement at tatgue m cancer patients. Further vakdtton ot the Fabgue Symptom Inveakxy* 9(7),
2000. page 847-854. DM Ham. M.M. Dennraton and F Baker, table l
Sample Exercise of diagnosis. To top it off, most survivors are over

age 60. Put this all together and the complexity of
Prescripti 매 s altering exercise prescriptions for cancer surxivors
becomes readily apparent.
There is so much to learn about cancer, how it is A single text cannot provide a program descrip
treated, and how those treatments might affect the tion for every possible combination of cancer site,
survivor. Further, this is layered on top of the need treatment, and medical history that a cancer fitness
to understand the basics of training for the generally professional will encounter. This section presents
healthy person. Add to this the high likrlihcxxi that sample programs for two survivors as examples of
survivors will also be overweight be sedentary, and how to synthesize all of the information contained
have several cardiovascular risk factors at the point in this book into personalized exercise prescriptions.
Program 1
Client Description
This person is a breast cancer survivor, diagnosed three years ago, who is generally healthy,
currently age 65. overweight and sedentary, but with no other comorbidities. Treatment with
cartx)platin resulted in persistent penpberal neuropathy. She has lymphedema in her left arm as
a result of having had six lymph nodes removed. She reports no other lingering adverse effects
of treatment. She takes trastuzumab (Herceptin). Her fitness evaluation reveals that she has low
muscular strength, poor cardK>respiratory endurance, and limited ability Io raise her left arm higher
than he『 shoulder. Balance, agility, and coordination results are within age-matched normative
ranges.
Fitness Goals
Her goal is to return to horseback riding. She has not ridden in 20 years, and she has not
participated in any regular exercise program in 10 years. Horseback riding will require her to have
stamina, agility, coordination, flexibility, and balance, as well as muscular strength and endurance.
Therefore, the fitness program should include activities to enhance each of these fitness domains.
The intensrty level tor horseback riding is estimated to be 4 METs, but could be higher, depending on
specifics. Muscular strength, cardiorespiratory endurance (stamina), and upperbody stretching are
the first domains of fitness that should be emphasized for the client to reach her goal.
Safety Concerns
The client is currently sedentary. The major limitations and concerns for exercise prescription for
this person may be her lymphedema; the penpheral neuropathy from her chemotherapy treatment
(platinum-based chemotherapy), which may alter her ability to hold weights (if the neuropathy
is in her hands); balance and the likeHhood of falls (if the neuropathy is in her feet): and her
cardiorespiratory response to aerobic exercise (given the cardiotoxicity of several treatments and her
poor general conditioning).
The initial prescription for this client coukl be the following:
Cardiorespiratory Exercise
• Three times weekly for 20 minutes, starting at a comfortable pace
• Modes of aerobic activity can vary from weight-supported aerobic activities to swimming or biking.
• Increase intensity and duration in aflernating weeks, and by no more than 10% per week until she
reaches the U.S. DHHS guidelines of vigorous-intensity exercise or has increased the number of
sessions per week to meet the U.S. DHHS guidelines for moderate-intensity exercise.
Strength Training
• Two times weekly, one set for each major muscle group
• 8 to 10 exercises
• 48 hours between sessions
It is vital that this program be supervised for the first several months and that the client s
lymphedema be stable (no recent acute increases in swelling or symptoms that have required
treatment by a lymphedema therapist) during any upper七ody strength training programming. Further,
the client should wear a well-fitted compression garment during these sessions. She should opt for
(continued)
109
Program 1 (continued)
variable resistance machines rather than dumbbells because of the peripheral neuropathy. Lower-
body exercise can proceed as with any other client, unless peripheral neuropathy interferes. If so. the
program should be altered the same way for the upper and lower body. For the upper body, the client
should start with the lightest possible weights and progress by the smallest possible increments
after she has had two to four sessions at the same weight that resulted in no change in lymphedema
symptoms. The limited range of motion in the left shoulder should be considered when choosing
exercises. If the client experiences any changes in lymphedema symptoms, she should stop upper
body strength training and consult a certified lymphedema therapist. The lymphedema therapist must
clear the client for upper-body strength training before resuming.
Upper-body exercise training should be started in a supervised setting to ensure that the client
learns the proper biomechanics fo『 each exercise. The goal is to avoid increases in inflammation and
irûry as a result of improper form, because these are likely to exacerbate lymphedema. Therefore,
the increments of resistance progression should be small, and attention should be given to avoiding
the overuse of smaller muscles to do exercises intended for larger muscles. For example, the
woman should not finish a seated row (intended for strengthening the large muscles of the back)
by curling her wrists, because this will require more work from the small muscles of the wrists than
they are abie to do and may result in an injury or inflammatory response that would exacerbate her
lymphedema.
Regular performance of weight training (two or three times per week) is necessary for ensuring
that this mode of exercise is useful and safe. If the client cannot attend regularly because of other
life commitments, progressive strength training should not be included in her exercise prescription.
For example, if she comes to exercise twice weekly for a month, but then has to go away for several
weeks to care for a family member, then returns tor three weeks (twice weekly), then has a business
trip for a week, then comes twice weekly for two weeks followed by a vacation for two weeks, she
should not ncreaee (progress) the weights; rather, she should continue Io use the lightest possible
resistance. Only those who are able to attend sessions on a regular basis over the course of more
than a month should progress resistance. All clients wi_ take "exercise vacations- during iNness and
when other life events preclude participation. This client with lymphedema, however, should back off
on the resistance when she has had a gap in exercise performance of a week or more, to avoid the
inflammatory responses that can exacerbate lymphedema.
Stretching
• Stretch aN major muscle groups at the end of each exercise session.
• Focus special attention and extra time on gradually increasing range of motion in the left arm and
shoulder.
Summary have been shown to tolerate aerobic exercise.3* That

said, fitness professionals should know the general
Advice given to the general public is likely excellent medical and cancer treatment history of each person
advice for all cancer survivors: Avoid inactivity. for whom they plan to develop an individualized
It is likely that all but a very small proportion of exercise plan. The combined knowledge of cancer
cancer survivors can build to 150 minutes per week treatment history and the recently published ACSM
of physical activity, even if on some days during guidelines for exercise in cancer survivors allows
active treatment they will require more rest than for the development of individualized activity pre
they do on other days. Even those undergoing treat scriptions that will minimize risk while maximizing
ments such as intensive chemotherapy for leukemia the benefits of exercise in this growing population.
Program 2
Client Description
This client is a prostate cancer survivor diagnosed one year ago who completed treatment within the
past six months. He has cardiovascular disease and is diabetic, age 70. overweight, sedentary, and
osleoporotic. He reports no bngering side effects from the treatment, and he takes beta blockers for
hypertension. He has not been regularly physically active since college. Hts fitness evaluation reveals
low cardiorespiratory endurance and poor flexibility. Strength testing was not performed.
Fitness Goal
His goal is to continue to live independently and to be able to get himself to the floor and back up so
he can play with his grandchMren.
Safety Concerns
This client s history is made up specitically to point out that cancer survivors often have
contraindications that are related to other chronic diseases. In this case, the client has cardiovascular
disease and diabetes. Therefore, guidance regarding exercise safety for a 70-year-old diabetic,
overweight, sedentary man with cardiovascular disease will come from the well-established ACSM
Guidelines for Exercise Testing and Prescription.25 Because he has known cardiovascular disease
and low fitness, he is a good candidate for a supervised exercise program.
Based on where the dient is starting and given the osteoporosis, it would be appropriate to start
with supervised cardiorespiratory exercise on a recumbent cycle ergometer, at an RPE of 6 on a
scale of 0 to 10. It would be inappropriate to prescribe exercise according to heart rate, given that
the client takes beta blockers, which blunt heart rate response to exercise. Common stretches for
general health would be appropriate. Evaluation of the ability to kneel and get to the floor and back
up will be needed, and the safety of strength training activity would need to be evaluated given the
osteoporosis. Medical clearance prior to initiating strength training or cardiorespiratory exercise
would be advisable.
References 4. Doyle C, Kushi LH, Byers T, Ccmmeya KS, Demark-

Wahnefried W, Grant B, McTieman A, Rock CL,
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2. Haskell WL Lee IM, Patv RR. Powell KE. Blair SN， 353.
Franklin BA, Macvra CA, Heath GW, Thompwn
5. Kushi LH, Byers T, Doyle C, Bandera EV McCuUough
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M, McTieman A, Gansler T, Andrews KS, Thun MJ.
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112 ACSMrs Guide to Exercise and Cancer Survivorship www.acsm乂)r玄
Aziz N, Bloch AS, Eldridge B, Hamilton K, Katzin C, factors, and effect on upper body function. / Clin
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Sawyer KA. Nutrition and physical activity during 16. Francis WC Abghan C Du W, Rymal C.Suna M, IG»ir
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MA. Improving surgical outcomes: Standardizing the
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20的 Sep-Oct 53(5)： 26R-291.
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8. Schmitz KH, Coumeya KS, Matthews C, Demark- lymph node dissection. Am f Surg. 2006 Nov; 192(5):
Wahnefried W, Galvao DA, Pinto BM, Irwin ML, 636^39.
Wolin KY, Segal RJ, Lucia A, Schneider CM, von
17. Karakaustb CE Dnsaill DL. Gftiin dissection in malig
Gruenigen VE, Schwartz AL American College of
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KH. An update of controlled physical activity triak Hovdrmakcr R，Wrhoef C, Grunhagen DJ, Schmitz
in cancer survivors: A systematic review and meta PI, E^gtOBHrit AM. de Wilt JH. Morbidity and prog
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AM, Baitbart \VS, Lvlh L). C impnch B, Ckvland C,
Eisenberger MA, Escalante CE Jacobsen PB, Kaldor E 20. Gleeson KL Immune system adaptation in elite ath
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659*665. 스々
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CHAPTER 7
Nutrition and Weight

Management
Stephanie Martch, MS, RD, LD, and Wendy Demark-Wahnefried, PhD, RD
following:
• Knowledge of common effects of cancer treatment on energy balance and body composition
lor individuals with nonmetastatic disease.
• Knowledge of effects of cancer cachexia on energy balance, intake, and actrvity level among
rxlividuflls with metastatic disease.
Knowledge of relationship between body composition as a nsk factor tor the development of
some cancers, and possibly as a risk factor for cancer recurrence.
Knowledge that many cancer survivors may use complementary and alternative medicine
(CAM) approaches, and of the potential for these remedies to influence exercise testing and
prescription parameters.
Ability to identify unintentional weight change that may relate to disease status, and recommend
that the dient seek appropriate medical attention.
Knowledge of effect of chemotherapy and radiation on the mouth and gastrointestinal system,
and the result of these changes on appetite and food preferences and choices.
Ability to discern when a participant's nutritional questions or status would be best managed
by referral to a registered dietitian.
Knowledge of current American Cancer Society nutrition guidelines during and after cancer
treatment.
Knowledge of hydration needs specific to cancer patients and survivors.
Knowledge of safety of weight loss programs for cancer survivors.
113
From a nutrition perspective, care for cancer ment, people must make informed and nutritious
patients and survivors can be both simple and food choices.
complex: simple, in that the nutrient needs and In 1981, Doll and Peto estimated that dietary
recommended food patterns are often the same as factors were directly associated with about 30 to
those for the population at large; complex, because 35% of cancer deaths.2 Although the methods to
disease-related treatments can trigger multiple scientifically pinpoint the exact magnitude of this
physiological alterations that inhibit the desire or relative risk still do not exist, this range is none
ability to eat However, this is also a time when theless accepted by the scientific community as a
cancer survivors may be highly motivated to make reasonable estimate. This estimate ranges between
lifestyle changes as a template for healing and to 10 and 90% depending on the type of cancer and
reduce the future risk of not only cancer, but also whether it is thought to be relatively unrelated to
other comorbid diseases. This chapter addresses the diet (e.g., hematological malignancies) or shows
assessment of weight-related problems, provides greater evidence of association , cancers of the
guidelines for the calculation of energy require colon, breast, prostate, and endometrium).
ments, and most important establishes principles Both the American Institute for Cancer Research
for healthy eating for various stages of cancer care (AICR), in collaboration with the World Cancer
and treatment, including recommendations about Research Fund (WCRF), and the American Cancer
when to consult a nutrition professional. Society (ACS) have issued nutrition-specific guide
lines for cancer preventicun and control1' (see table
7.1). These recommendations are for cancer survi
Diet in Cancer Prevention, vors and share many similarities with those created
Control, and Overall to prevent and manage other prevalent chronic

diseases (e.g.z cardiovascular disease |CVD|X diabe
Health tes, and osteoporosis), for which cancer survivors,
when compared to the general population, are at
Whether a person is cancer free or not, the essen significantly greater risk.*-1* (Table 7.2 provides
tial nutrients found in foods (carbohydrate^ pio- resources for specific nutrition recommendations
tein, fat vitamins, minerals, and water) are just related to these comorbid diseeRt*s.)
that—essential. These nutrients fuel the body and More than a decade agav Brown and colleagues
provide the necessary substrate to ensure optimal examined more than 1.2 million patient records and
physiological functioning A healthy body is about found overwhelming erkicrnctf that cancer survivors
60% water; 20% protein, carbohydrate, and bone die of noncancer causes at a higher rate than do
mineral compounds; 20% fa|; and less than 1% people in the general population, and almost half
vitamins and other minerals.1 We truly are what of these death포are due to CVD.17 Over the ensuing
we eat, and to optimally function, espedaDy while years, sever' other studies have shown that cancer
managing the burden of cancer and related treat survivQCare at increased risk for second malignan-
Nutrition Professional for Cancer Treatment

Registered dietitians (RDs) are specially trained to translate nutrition research into healthful diets.
The RD credential is available to those who obtain a bachelor's degree in nutrition accredited
by the American Dietetic Association (ADA), complete an ADA-approved internship, and pass a
comprehensive written exam covering all aspects of nutrition therapy. To maintain this credential.
RDs must regular^ participate in ADA-approved continuing education programs. The ADA also has
an advanced-level certification process for RDs specializing in oncology nutrition. To find an RD
in their area, fitness professionals should speak with their client's oncologist, or visit the American
Dietetic Association s website at www.eatright.org and select Tind a Registered Dietitian?
Nutrition and Weight Management 115
TABLE 7.1 Nutrition Recommendations for Cancer Prevention

American Cancer Society World Cancer Research Fund/
American Institute for Cancer Research
Healthy weight Achieve and maintain a healthy weight if Be as lean as possible within the normal
currently overweight or obese. range of body weight.
Avoid excessive weight gain throughout
the life cycle.
Balance cakxic intake with physical
activity.
Choose foods and beverages in amounts Limit consumption of energy-dense foods.
that help achieve and maintain a healthy Avoid sugary drinks.
weight.
Diet (emphasis Eat five or more servings of a variety of Eat mostly foods of plant origin.
on plants) vegetables and fruits each day.
Choose whole grains in prelerence to
processed (refined) grains.
Limit consumption of processed and red Limit intake of red meat and avoid
meats. 一』 processed meat.
Alcohol Drink no more than one drink per day for Limit alcoholic drinks.
women or two drinks per day for men.
Preservation, Limit consumption of salt.
processing,
preparation
Dietary Consume needed nutrients through food Aim to meet nutritional needs through diet
supplements sources. alone.
Adapted fetxn Doyte e( at 2006.. World Cancer Reaearm AmkIAmerican institute tor Cancer Research 2007*.
TABLE 7.2 National Health Association Professional Statements of Nutrition

Recommendations for Comorbid Disease Prevention
Disease or syndrome Organization Website
Cardiovascular American Heart Association http7/circ.ahajournals.org/cg^reprint/102/18/2284
Diabetes American Diabetes httpy/care.diabetesKXjrnals.org/cgi/reprint/31/
Association Supplement. 1 /S61
High blood pressure Natkxial Institutes of www. nhlbi.nti .gov/health/public/heart/hbp/dash/
Health; National Heart, r dash_bnef.pdf
Lung and Blood Institute
Osteoporosis Centers for Disease Control www.cdc.gov/nutrition/everyone/basicsAîtaniins/
and Prevention calcium.html
cies as well as other comorbidities?*42 The magnitude vives have unmet needs for adequate health care
of this problem, however, has gained increasing posttreatment in 2005 the Institute of Medicine (IOM)
attention as the population of survivors has grown issued a report calling for increased efforts targeting
dramatically and cancer survivors now comprise the health care needs of this growing population,
approximately 4% of the US. population.23 In addi including efforts to improve nutritional status.25
tion, these sunivors have almost a twofold increase For people with cancer and undergoing cancer
in functional limitations that threaten their ability to treatment, normal nutrition rvcommendations may
live, work, and function independently, particularly no longer suffice. Many cancers create a body state
at older ages.24 Recognizing that many cancer sur in which problems of nutrient deficiencies, loss of
116 ACSMrs Guide to Exercise and Cancer Survivorship www.acsm.Or玄
lean body mass, and treatment-induced nutrition- some hypothesized pathways include increased
related side effects may compromise the ability to levels of endogenous hormones or hormone-
secure optimal nutrition.4 Certified Cancer Exercise related factors (e.g., sex steroids, leptin, insulin
Trainers (CCET) design and implement physical and insulin-like growth factor-1); decreased levels
activity programs best suited to patients thnmghcxit of binding proteins, which results in higher levels
the weight spectrum. This chapter addresses basic of free circulating hormones; increased availability
nutritional assessments and provides basic nutri of substrate such as glucose and free fatty acids;
tional guidance and reinforcement; it also provides decreased apoptosis via suppressed glucixx)rt)coids;
helpful benchmarks for recognizing when a referral decreased T helper (Th2) factors; and enhanced
to a nutrition professional is warranted. immune response via various adipokines and
eicosanoid-mediated events.*次,’®
Weight gain, which is common during and after
Weight Status and Body treatment for a variety of cancers, reduces quality
of life and exacerbate* the risk far functional decline
Composition and comorbidity.4 나 노 Moreo\ er;an werv\rhehning
number of cancer survivors struggle with excess
The prevalence of overweight and underweight in weight, including more than 70% of breast and pros
cancer patients often follows a site-specific pattern. tate cancer survivors■_the two largest populations
Survivors ofearly-stagp prostate and breast cancers of adult cancer survivors in the United States■一as
frequently are overweight at diagnosis and gain well as survivors of acute lymphoblastic leukemia,
weight during treatment. Those being treated for a prevalent cancer among American children.®-37
cancers related to eating (e.g., esophageal, head and Although studies exploring the relationship
neck, and stomach cancer》not surprisingly often betu een postdiagnosis weight gain and disease-free
experience problems with appetite, ingestion, and survival have been somewhat inconsistent,4 MMr3B
absorption that lead to tissue wasting and weight one of the largest cohort studies found that breast
loss, both of which can profoundly affect physical cancer survivors who experienced an increase of at
functioning and the ability to tolerate subsequent least 0.5 body mass index (BMI) units postdiagnosis
treatments. Weight and body composition assess had a significantly higher risk of rvcurrvnci, and all
ments provide baseline data to help fitness profes cause mortality.'' This accumulating evidence of the
sionals monitor the outcomes related to nutrition adverse effects of obesity in oncer survivors makes
therapy. 屬'
weight management a priority for survivorship, *•
a*. «■ 細 Furthermore, the cancer diagnosis may create
Overweight and Obfesity a teachable moment that may motivate people who
have been denying weight gain and dehying action
Obesity contributes to roughly 40,000 US. cancer
on weight management to participate in health
diagnoses annually and plays a significant role in
promoting flanges.4 s 39
breast (pcistnienopAusalK colon，kidney* endome
trial, gallbladder (in women), and upper stomach
cancers. 公 건，Moreover, overweight and obesity may
account for 14 to 20% of all cancer*related deaths_ 겨양 Take-Home Message
including multiple myeloma; non-Hodgkin's Patients caring for family mem
lymphoma; and cancers of the uterus, cervix* bers may feel guilty about in
breast, prostate, colon, rectum, esophagus^ stmn- troducing dietary changes into
ach, gallbladder, pancreas, and liver.27 M Although the family's long-standing way
overweight and obesity contribute to the primary of eating. Fitness professionals can remind
risk of select cancers, their contribution to cancer these clients that nudging family members
promotion (i.e., growing the tumor once it is estab toward healthier eating is in fact a caring
lished) is exceptionally important thing to do, because it can reduce disease
The exact mechanisms by which overweight and risk, parbcularty for offspring wtx> may be
obesity contribute to cancer initiation and promo geneticaly susceptible.
tion have yet to be firmly established. However,
Although the pursuit of a desirable weight can Underweight

be postponed until primary treatment is complete,
fitness professionals should be aware that among On the other end of the scale (literally and
patients who are overweight or obese, there are no figuratively), some patients, such as those uith
amtraind ications to a modest rate of weight loss (no aerodigestive tumors, tend tp be underweight
more than 2 lb, or 0.9 kg, per week) during treatment, at the time of diagnosis. Moreover, these same
as long as the oncology care physician approves and patients, as well as others, can experience unin
it does not interfere with treatment.4, M M tended weight km secondary to treatment-related
The sidebar Nutrient-Dense Eating Strategies for surgery, chemotherapy, and radiabon therapy. In
Weight Management offers weight management addition, anorexia and cachexia can place some
strategies to recommend for promoting the intake cancer paturnh at risk for compromhieci nutritioruil
of lower-calorie, nutrient-dense foods. Diets that status.*'^ In most early-stage cancers, weight loss
rely heavily on these foods can aid in weight man is fairly rare; however, with more aggressive and
agement, as well as increase the chance of taking in laler-staê tumors, especially cancers of the lung,
adequate nutrition. gastrointestinal tract, pancreas, head, and neck,
Nutrient-Dense Eating Strategies for Weight Management

Eat More
• Fruits and vegetables
• Slice to make them ready-to-eat while watching TV, for the car trip home, at work.
- Try homemade fruit smoothies.
• Whole graine
- Have oatmeal for breakfast.
- Make sure the first ingredient on your bread or cereal label is a whole grain.
• Broth-based soups
• Foods with high nutrient density (e g., legumes; dark green, yellow, and orange vegetables; fruits:
whole grains; lean meats; nonfat milk products; and, in moderation because of their high fat con
tent nuts and seeds)
Eat Less (or Fewer)

• Fat (and saturated fat)
- Trim fat from meats; remove skin from poultry.
- Broil or bake instead of frying.
- Choose low-fat dairy products.
• Ask for salad dressing on the side, and choose low-tat or nonfat dressings.
• Choose broth- instead of cream-based soups.
- Use liquid oils (olive and canola oil) instead of solid fat (butter, margarine, shortening, lard).
• Simple sugars
• Avoid beverages with added sugar or corn syrup. Choose water, unsweetened tea. or diet
beverages.
- Limit added white and brown sugar, honey, rrxMasses. and raw sugar.
- Limit intake of pies, cakes, candies, and pastries.
Substitute
Legumes and soy meat substitutes for meat and meat products
weight loss is a common and characterizing symp Cancer cachexia, most commonly associated with
tom.41 w The lcs» of less than 5% of body weight, lung and gastrointestinal tract cancers as well as a
especially among patients presenting with either variety of advanced-staged cancers, differs from
a normal or lower BM1, is associated with poorer typical anorexia-induced starvation.52 Indeed, the
treatment tolerance and outcomes and pcxirer body normally adapts tu starvation by triggering
quality of life,*4-17 and is a significant predictor of metabolic alterations to preserve lean body mass, by
reduced survival rates.*1 은50 shifting toward fatartabolism. With cachexia, how
Factors that contribute to weight loss, many ever, tumor-induced alterations upset normal tissue
of which stem from chemotherapy and radiation repair, wherein cytokines and eicosanoids appear
therapy, include appetite loss, early satiety (feek to medial? an inflammatory .tike catabolic response
ings of fullness), an altered sense of taste and smell, in which lean body mass, in addition to stotvd fat,
chewing and swallowing difficulties, nausea, is lost4* E Cachexia cannot be reversed by food
vomiting, diarrhea, and compromised nutrient intake alone,41, *'•M and it becomes imperative to
intake.4 사 The sidebar Nutrition Recommendations aggressively identify and treat nutrition-related
for Common Symptoms of Cancer Treatment pro side effects to help stabilize or reverse weight k»s.M
vides recominendations that fitness professionals The Nutrition Screening Initiative—a project of
can propose to address these symptoms among the American Academy of Family Physicians, the
patients, while advising those who experience American Dietetic Association, and the National
severe weight loss to seek professional nutritional Council on Aging一devised a brief nutritional
care.'1 Note: Severe weight loss is indicated by a screening tool that fitness professionals can use
loss in body weight of >2% per week, >5% per to identify underweight (and overweight》clients
month, >7.5% in three months, or >10% in six requiring intensive professional nutrition therapy
months. (see figure 7.1).
A
Nutrition Recommendations for
Common Symptoms of Cancer Treatment
Anorexia (Loss of Appetite)

• Increase energy- and protein-dense foods such as peanut butter, nuts, milk, cheese, yogurt,
eggs, legumes, granola, and dried fruit
• Eat smaN, frequent meals, or three small meals plus several snacks.
• Seek out favorite foods and foods that smell good.
• Try bland, unspicy foods.
• Look tor foods that smell good.
• Try meal-replacement beverages.
Nausea and Vomiting

• Focus on bland foods.
• Avoid strongly scented foods.
• Take small sips of fluids or suck on ice chips.
• Eat crackers, dry toast, or plain cookies.
• Try beverages such as Gatorade or Pedialyte.
• Rinse mouth before and after eatng.
Nutnbon Recommendations foe Common Symptoms o< Cancer Treatment (conbnued)
Mucositis or Stomatitis (Mouth Sores)

• Eat foods at room temperature.
• Choose liquids high in nutritional value (mik. 100% juices, meal-replacement drinks); use a straw.
• Cut foods into small pieces.
• Choose soft and soothing foods such as frozen desserts, milkshakes, baby foods, bananas, ap
plesauce. fruit nectars, mashed potatoes, cooked cereals, soft-boiled or scrambled eggs, cottage
cheese, macaroni and cheese, puddings, gelatin, pureed foods, and liqukl supplements.
• Avoid tomatoes, citrus fruits and juices, salty or spicy foods, raw vegetables and fruits (unless soft
and npe). beverages containing caffeine or alcohol, pickles, vinegar, chocolate, and rough or dry
foods (e.g., tortilla chips).
Xerostomia (Dry Mouth)

• Choose foods that are soft and moist, such as hot cereals, soups, tuna or egg salad, smoothies,
casseroles, and fruits.
• Drink 8 to 12 cups of fluid per day, suck on ice chips, o『 try tart foods to stimulate salrva production.
• Avoid
• Caffeine, alcohoi, and aicobol-coataining mouthwashes
- Dry, crumbly foods
• Satty ex spicy foods
Taste and Smell Abnormalities or Food Aversions

• Eat small, frequent meals and snacks.
• Add spices and sauces.
• Eat meats with something sweet.
• Experiment with temperature; cakf foods often are acceptable, whereas hot foods may not be.
• Use plastic utensils (if food tastes metallic).
Diarrhea
• Drink 8 to 12 glasses (at least an 8 ounce glass) of fluids, including drinks such as Gatorade or
Pediatyte.
• Avoid alcoholic or caffeine-containing beverages.
• Choose eggs, well-cooked; lean meats, poultry, and fish; smooth peanut butter; beans; low<fat
milk, yogurt, or cottage cheese; cooked vegetables: fruits without the skin; and desserts low in fat
(sorbets, fruit ices, graham crackers).
• Avoid fried or fatty meats; pizza; full-fat milk or cheese; raw vegetables; dned fruits; spicy foods;
high-fat desserts or ice creams; candies or gums containing sorbitol, mannrtol. or xylitol.
Constipation
Eat more fibeF-containing foods (bran, whole grains, fruits, and vegetables).
From Amerioan C«ic_ SocMly.
119
Figure Z1 Determme Your Nutritional Health
The warning signs of poor nutritional heatth are often overlooked. Use this checklist to find out if you or
someone you know is at nutritional risk.
Read the statements below. Circle the number in the yes column for those that app^y to you or someone you
know. For each yes answer, score the number in the box. Total your nutritionaJ score.
YES
1 have an illness or condition that made me change the kind or amount of food 1 eat. 2
1 eat fewer than two meals per day. 3
1 eat tew frurts, vegetables, or dairy products. 2
1 have three o『 more drinks of beer, liquor, or wine almost every day. 2
1 have tooth or mouth problems that make it hard for me Io eat. 2
1 don't always have enough money to buy the food 1 need. 4
1 eat alone most of the time. 1
1 take three or more different prescribed or over-the-counter drugs a day. 1
Without wanting to, 1 have lost or gained 10 pounds in the last six months. 2
I am not always physically able to shop, cook, or feed myself. 2
TOTAL
Total your nutritional score. If it’s—

0-2 Good! Recheck your nutritional score in six months.
3-5 >bu are at moderate nutritional risk. See what can be done to mprove your eating habits
and lifestyle. Your office on aging, senior nutrition program, senior citizens center, or health
department can help. Recheck your nutritional score in three months.
6 or more Ybu are at high nutritional risk. Bring this checklist the next time you see your doctor, dietitian,
or other qualified health or social service professional. Talk with them about any problems you
may have. Ask for help to improve your nutritional health.
Remember that warning signs suggest risk, but do not represent diagnosis of any condition.
The Nutrition Checklist is based on the warning signs described below. Use the word DETERMINE to
remind you of the warning signs.
Disease
Any disease, illness, or chronic condition that causes you to change the way you eat, or makes it hard for
you to eat, puts your nutritionaJ health at risk. Four out of five adults have chronic diseases that are affected
by diet. Confusion o『 memory loss that keeps getting worse is estimated to affect one out of five or more of
older adults. This can make it hard to remember what, when, or if you've eaten. Feehng sad or depressed,
which happens to about one in eight older adutts. can cause big changes in appetite, digestion, energy
level, weight, and wel-being.
Eating Poorly
Eating too little and eating too much both lead to poor health. Eating the same foods day after day or not
eating fruit, vegetables, and mHk products daily wiN also cause poor nutritional health. One in five adults
skips meals daily. Only 13% of adults eat the minimum amount of fruits and vegetables needed. One in four
120
older adults drinks too much alcohol. Many health problems become worse if you drink more than one or
two alcoholic beverages per day.
Tooth Loss or Mouth Pain

A heahhy mouth, teeth, and gums are needed to eat. Missing, loose, or rotten teeth or dentures that don't fit
well or cause mouth sores make it hard to eat.
Economic Hardship
As many as 40% of older Americans have incomes of less than $6,000 per year. Having less―or choosing
to spend less than $25 to $30 per week for food makes it very hard to get the foods you need to stay
healthy.
Reduced Social Contact

One third of all older people Hve alone. Being with people daily has a positive effect on morale, well-being,
and eating.
Multiple Medicines
Many older Americans must take medicines for health problems. Almost one haff of older Americans take
multiple medicines daily. Growing old may change the way we respond to drugs. The more medicines you
take, the greater the chance for side effects such as increased or decreased appetite, change in taste,
constipation, weakness, drowsiness, diarrhea, or nausea. Vitamins or minerals when taken hi large doses
act Ike drugs and can cause harm. Alert your doctor to everything you take.
Involuntary Weight Loss or Gain

Losing or gaining a lot of weight when you are not trying to do so is an important warning sign that must not
be ignored. Bemg overweight or underweight also increases your chance of poor health.
Needs Assistance in Self-Care

Although most older people are able to eat, one of every five has trouble walking, shopping, buying, and
cooking food, especialty as they get older.
Elder Years Above Age 80

Most okle『 people lead full and productive lives. But as age increases, risk of frailty and health problems
increase. Checking your nutritional health regularly makes good sense.
From 4CBM. 2012. ACSM a to ewoM and cancer 베 Cham(k_gn. I: Human Kmenct) Raprintied iroai B. 1W6.and
haadhT/Vnencan Physician (57)5.03304. Arnones AcaHeotf of Fam~ Pny_ctans_ Aw_katte onlne at hlpJ/www.Mip.0fg/atp9e0301 ap«edts.h«nl
Weight and Height in weight, particularly when unintentional, can be

difficult to overcome if not immediately addrestsed.
Assessment Because weight changes are common along the
cancer continuum from diagnosis and treatment
Weight status may be the fitness professional’s to recovery and survivorship, it is good practice to
most valuable and accessible tool in assessing record a precancer weight as a reference point, and
cancer-related health status. Even small changes to use this to calculate weight change at each visit.
Weight Change Calculation

Current weight (lbs) - Prccancer weight (lbs)
----------------------------------------------------------- X 100 = Percent weight change
Precancer weight (lbs)
Calculating a reasonable body weight can be or shorter than average. See table 7.3 for concepts
helpful for setting goals for both the under- and related to weight management in cancer treatment.
overweight. The Hamwi method is preferred by People being measured for height should be
many clinicians because of its ease of use and com standing straight, without shoes, heels together,
mitment to memory:'' shoulders back, and head level; height is recorded
after they have taken and are holding a deep breath.
Hamwi Estimation for Reasonable If height cannot be measured because of illness,
Body Weight arm span measurement can serve as a surrogate
Women: 100 lb (45 kg) ♦ 5 lb (23 kg) for each inch (2_5 for height5* To be measured this way, the person
cm) in height over 60 in. (152 cm) extends her arms out to her sides, parallel to the
Men： 106 lb (48 kg) ♦ 6 lb (2.7 kg) for each inch (2.5 cm) floor, with palms facing forward.v The distance
in height over 60 (152 cm) from one middle fingertip to the other middle
The fitness professional may wish to adjust for fingertip across the shoulders at the clavicle level
height by adding or subtracting 10% from the result is measured (in inches) (see figure 72j. Height can
ing value if a person's height is significantly taller then be calculated using the following formula:56
TABLE 7.3 Summary of Weight Management in Cancer Treatment*

Weight
status Definition Health risks Goals Suggested strategies*
Normal BMI = 18.5-24.9“ Optimize Visit www.choosernyplate.gov tor
weight nutrient intake, food group recommendations kx
maintain desired weight by age, height, and
weight. gender.
Underweight BMI = <18.5 Malnutrition, poor Statxlize • Eat small, frequent meals (6-8
Mild BMI = 1Z0-18.49 prognosis weight; prevent times a day).
underweight loss of lean • Keep snacks handy.
body mass;
Moderate BMI = 16.0-16.9 prevent or • Eat energy*dense foods when
underweight experienang poor appetite (e.g.,
treat nutrient
Se；ere BMI = <16— dried fruit, sauces and gravies,
deficiencies;
underweight ice cream). •/
minimize
nutrition- • Consider liquid meal
related side replacements.
effects. • Address eating-related
symptoms
Overweight BMI = 25.0-29.9 Functional dedine; Lose up to 2 Reduce energy density of diet by
BMI c 30 or more comortxdities lb (0.9 kg) per doing the following:
Obese
(diabetes and week (secure • Increase fruit and vegetable
Class I 30.0-34.9 cardiovascular doctor's intake.
Class II 35.0-39.9 disease); cancers approval rf
• Increase the intake of foods
Class III H0.0— of the breast cunentfy
(postmenopausal), receiving that have high fluid or high fiber
contents (e g., broth-based
colon, kidney, pnmary cancer
soups, sugar-free gelatin,
endometrium, treatment);
gallbladder, unbuttered popcorn).
increase
pancreas, and physical • Umit the intake of fat and simple
gastric cardia activity and sugar.
(upper stomach); reduce energy • Limit the portion sizes of
progressive disease intake. energy-dense foods.
•Comtane dMary and physicai aclwtty »1ra_9M (m« chapotc 6) to acfaaw，n_gf daActts.
••A BMi b«w»an 1&5 and 22 표 « *axnmended by WCRF/AlCR lor apamal l、«a齡e
•••Refer these patients to a regstered dKtman
Also of concern is weight gain secondary to

hypothyroidism一found commonly in 15 to 48% of
head and neck cancer patients receiving treatments
targeting the thyroid gland, but also occurring in
people with other cancers as well.** *** Regular exami
nation with periodic thyroid function tests may be
warranted in these cancer survivors, because hypo
thyroid ism may go unrecognized, and subsequently,
untreated.- *9 Be aware that certain symptoms
common with hypothyroidism―edema, fatigue,
weakness, mujicle pain, dry skin—mimic those often
stemming from the cancer itself or its treatment*18
Adiposity ana Body

Com position Assessment
Although the use of BM1, or the Quetelet Index, has
become a standard assessment technique for esti
mating obesity of populations, because of the ease
of coUecting weight and height measurements (see
the sidebar BMI Calculation), caution must be used
with this approach?1.’1 Simple weight and height
Height Calculation (Arm Span measurements do not distinguish between lean and
fat tissue. In fact, because BMI is an assessment of
Method):
heaviness, it can be abnormally high in those with
Height (inches) ■ (0.87 X arm span (inches]) + 20.54 ascites, edema, a well-developed musculature, or a
large, dense skeleton; or abnormally low as a result
Adiposity and Bodv^ of muscle wasting or osteoporeniis.72 As such, BMI
Composition £ should be viewed as a proxy for assessing body

fatness, and is best used as a screening measure for
It is important to use caution when evaluating the disease risk71-n
weiît status of cancer patients. Fluid retention from
<183 = Underweight
ascites or edema coexisting with lean body mass loss
18.5-24.9 = Normal weight
can present a picture of weight stability. Normal
weight gain involves increases in both lean and adi 25.0-29.9 : Owrweight
pose tissue, whereas a distinct form of weight gain, 30.0-34, : Moderate obesity
sarcopt-nic obesity, refers to a weight gain largely 35.0-3^9 = Sevetv obesity
composed of fait, but not lean tissue.* This phenom ^40 = Very severe ar morbid obesity
enon has been reported in 50 to 90% of breast cancer
patients during the time of adjuvant chemotherapy; ii Within the "normal weight" category, and to
has also has been reported with hormonal therapies, maximize health potential, the WCRF/AICR guide
as well as in those being treated for solid tumors of lines endorse an even stricter BMI goal range of 18.5
the rr>pirakiry and gastnMntestiful tracts. Certain to 22.9 kg/m2?
、、
aromatase inhibitors may protect against the devel
opment of sarcopenic weight gain, although results Z
are conflicting.*1' Physical activity, particularly resis BMI Calculation
tance training, is currently the comerstone for both
the prevention and treatment of this type of obesity* Metric: Weight (kg) / height (m)2
Fitness professionals are obviously well qualified to U.S. units: Weight (lb) x 703 / height (in^
play a major role in managing this syndrome.
Waist circumference (WC) serves as a fairly reli be difficult to locate).76 The tape should be hori
able measure of abdominal fat and has been associ zontal to the floor, and the patient should exhale
ated with abnonnal blood lipid levels, hypertension, slowly prior to the reading, which is observed
insulin resistance, and diabetes.7174 Established indi by pulling the tape so that it is snug, but without
cators of high risk are the WC cut-points >102 cm compressing the skin. Ideally, nonstrvtch tape
(>40 in.) for men and >88 cm (>35 in.) for women.B measures Mth tension-control features (often used
In years that predated the US. National Institutes in research studies) should be used to obtain the
of Health ci)nsen»us report on the identification, most accurate readings More important, however
evaluation, and treatment of overweight and obesity is the use of consistent technique across all waist
in adults/1 the use of a waist-to-hip ratio to assess assessments.
health risk was common; however, it is used less Other methods to assess body fat levels (skin
frequently today, because WC alone is considered fold thickness measurements, dual-«ierg\, X-ray
a more reliable measure/4 absorpttrnnetry (DXA]Z whole body air-displace-
The two most commonly used WC assessment nwnt plethysmography |BOD POD), hydrodensi-
techniques are as follows: (1) place the tape at the tometry |underwater weighing]z and bioelectrical
natural waist, halfway between the lowest rib impedance) require assessment by a skilled techni
and the iliac crest (mark the bony protuberances cian using regularly calibrated, and often costly,
on both sides and then mark the halfway point equipment/4 77•n Of note is the fact that although
between the two measures; ensure that your tape bioelectrical impedance devices are frequently
cxjvers both halfway marks—see figure 73); or (2) available to the public, consumer models often
place the tape at the umbilicus level (often chosen forgo the standard pretest legimens for hydration,
for obese subjects, because bemy protuberances can physical activity, and food and beverage consump
tion; furthermore, they omit the standardization
of ambient air and skin temperatures and body
electrode positioning (hand + foot) necessary
for accurate clinical measurements.74,Another
method, near infrared interactance一frequently
used in Ktness and athletic facilities to estimate
body fat—involves sending an electromagnetic
^gnal into the biceps of the nondominant arm.72
This signal, based on the water, protein, and fat
composition of the subject, is scattered and reflected
back for measurement. Reference standards for this
technique have not yet been validated in humans,
and variability of values is fairly broad. Thus, its
limitations appear to outweigh its advantages, such
as ease of use.72 In contrast, DXA is increasingly
recognized as a gold standard for assessing body
composition, and also is able to discern lean and
adipose tissue distribution in various body regions.
However, as stated earlier, its use may be limited
to research endeavors/4
To assess muscle mass changes, a measure of
mid-arm muscle circumference (MAMC) can be
made using a nonstretch, tension-controlled tape.74
The measure is taken at the midpoint of the upper
arm between the acromion process and the tip of
the olecranon while the arm hangs naturally by the
Figure 7.3 Tape placement for waist
side with palm facing forward (see figure 7.4). The
circumference measurement.
tape should not compress the skin. Btness profes
Reprmted from Nafeonai Heart and Lung InsMutB 1998. Aveteble: www
讀
nt >i nti txSA/txgdM I42.htm sionals should keep in mind that, at least among
against cancer, but this population's level of energy

restriction was of lesser magnitude than that found
to slow tumor growth in animal models.113
To avoid weight gain, energy intake (measured
in cakiries) must be bahnerd against energy expen
diture. Ingestion of 3,500 calories in excess of what
is needed—for body metabolism, processing of
food, and physical activity—results in approxi
mately 1 pound (05 kg) of weight gain. To lose 1
to 2 pounds (0.5 to 1 kg) per week, a person must
ClMie-
have a daily deftdt of 500 to 1,000 calories (cither
Acromaon
as reduced intake, increased expenditure, or a com
bination of both). Trends in populMion-based data
suggest that Americans, in fact, Me eating more and
exercising less. From 1971 to 2000, calorie intakes
increased by 7% in men and 22% in women, while
chosen portions, particularly of high-energy dense
foods, got larger.，"5 At the same time, more time
was spent on s^sdentary work-related activities in
lieu of leisure activities. Less physically exerting
activities such as driving a car, office work, and
Olecnnon televbAon viewing, became the top three means
of energy expenditure, even though these activi
ties bum relatively few calories per hour.8** Cancer
Figure 7.4 Measure mid-upper-arm type and stage can alter metabolic raten by 50 to
circumference by placing the tape 175% of predicted levels, affecting both energy
From ROLFESyPlNNA^HITNEy. balance and weight status.®7 M An awareness of
Nutrtnn. BE C 2000 BrookaCoii
AepoduMdbypemwaton ww«c these associations prepares fitness professionals
to work unth nutrition praiessionals to adjust diet
and exercise prescriptions to help patients meet
Americans, arm fat deposition varies substantially,
their weight goals
and the inconsistencies in musde mass changes
identified with this technique may make it less
useful for interindividual comparisons.*4
Take-Home Message
Why do most people choose
36372225 the foods they do? Because
and Cancer they taste good is the primary

reason. Fitness professionals
In laboratory animals, restricting energy cimsump* should discuss with their patients how they
tion by 60 to 80% of normal slows tumor growth can begin to alter their food-related thought
and extends the life span by upwards of 28%.* n processes. Can they begin to eat for health
Although it may be difficult to pursue randomized instead? How would that change their food
controlled trials of energy restriction in humans, choices?
observ ational data on women undergoing puberty
during World War "-imposed food shortages
show a reduced lifetime risk of breast cancer when Total energy needs are comprised of fuel
compared against younger and older cohorts.® On expended (1) at rest (resting metabolic rate |RMR|)#
the other hand, recent results from a large study (2》during the digestion and absorption of food
(n = 28,098) conducted over 16 years found that a (approximately 10% of energy intake), (3) during
(self-reported) low calorie intake did not protect physical activity, and (4) to meet the metabolic
demands of compromised health status (e.g” infec- Underweight adults 30-35 calories/kg
tion, recovery from physical injury or surgery, or Sc%,erely adult** 235 calorie*/k표
disease-related trauma).72 In most cases, RMR is the
primary contributor to energy needs (it accounts 'Stress refers to a metabolic derangement common in cancer
WMnenl norm- cormcttw meuboAc adaptatkxw do not
for 60 to 75% of the total) and far overshadows
occur. The oncologM or registered Mitian assesses symptoms
energy needs for physical activity.72 Of note, and laboratory values to determtne the level of stress.
RMR is largely driven by two factors: external
temperature (any deviation from 78 °F, or 26 °C,
requires increased energy use) and lean body or
muscle mass (i.e., tissue that is metabolically quite
Take-Home Message
When talking about what to eat.
active).72 Exercise can therefore indirectly influ*
patients often are interested in
ence er、ergy needs through its effect on muscle
mass—mass that may be diminishing as a result
knowing an exact calorie pre
of cancer treatment or the normal aging process,
scription. Frtness professionals
should let them know that, without expen
both of which exercise can ameliorate. As stated
sive equipment, such calculations are gross
earlier, cancer also can influence energy needs dra
matically一large increases over basal levels may be
estimates at best. It's far better to focus on
improving the nutrient densrty of food choic
anticipated if tumor burden is high and/or if the
es by reducing tats and sugars and eating
cancer is situated in highly metabolic tissues or in
more fruits, vegetables, and whole gram.
those that directly influence energy balance (e.g.,
In addition, portion control is also important
the thyroid gland).
Total energy needs can be measured via direct
Behavioral strategies, such as keeping a
calorimetry, which requires an oremight stay in d
journal of the foods consumed, eating skxwly
highly sophisticated chamber capable of measur
and defeberately. and reducing exposure to
food also are key strategies for weight man
ing the amount of heat (directly related to energy
use) released by the body,4 Because this technique agement.
is impractical in most clinical settings, other meth-
ods have been developed to assess energy needs.
The indirect calorimeter determines resting energy The ACS guidelines recommend referral to a
needs by measuring oxygen intake and carbon registered dietitian of all cancer patients who are
dioxide output with a portable device. This value having tremble eating or gaining weight.4 By the
is then added to energy estimations for food pro same token, a referral often is indicated for patients
cessings physical activity, and health status. For who require guidance on weight loss diets. If weight
thoM* without access to an indirect calorimcterê loss is indicated, the dietitian will formulate plans
standard formula to estimate RMR may be used. that ensure the intake of adequate nutrients, and
The Mifflin-St. Jeor equation was deemed most adjust the patienfs energy level to ensure a weight
likely to yield results awn parable to th(M* obtained loss of no more than 2 pounds (0.9 kg) per week,
with caiorimetry?R because more rapid weight loss is apt to have
adverse effects on muscle mass.58
Men: Resting energy calorie needs «
(9.99 X weight |kg|) + (6.25 X height |cm))
- (4.92 x age |yr)) + 5
Women： Resting energy caloric nerds ■
Diet Compositi 에
(9.99 X weight (kg)) ♦ (6«25 x height |cm])
- (4.92 X age [yrl)-161
and Nutrition Status
The importance of good nutrition to cancer treat
Perhaps more simply, fitness professionals can
ment was highlighted in a length-of-stay study
estimate total energy needs for cancer patients and
that revealed that the average hospital stay of
survivors using one of the following formulas:**
well-nourished patients* was 5.8 days, whereas
ObeM* patients 21-25 cakxies/kg malnourished patients stayed an average of 13.4
Sedentary adults 25-30 calories/kg days.*2 Not surprisingly, poorly nourished patients
face diminished quality of life and less tolerance may enhance treatment efficacy. As such, the IOM
of therapy, which may result in lower survival endorses dietary reference intakes (DRls) for mac
rates.42 Being overweight or obese does not offer ronutrients, which directs dietary intake toward
protection from poor nutrition, especially when decTeasing the risk of developing chronic disease*
high-energy but nutricnt-dcxôid diets, which focus Current IOM reaimmendatkxis endorse 45 to 65%
on chips, sodas, cakes, and pastries, are consumed of energy from carbohydrate, 10 to 35% from pro
consistently.^ * tein, and 20 to 35% from fat.
Fitness professionals can guide food choices Carbohydrate provides glucose—the body、
based on the ACS and WCRF/AICR guidelines, primary fuel source and the preferred fuel for
thereby increasing the likelihood of adequate nutri brain, peripheral nerve, and red blood cell energy.
ent intake. One of the easiest ways to encourage the Adequate dietary carbohy drate conserves func-
adoption of a healthy diet (Le., low fat and nutri titMial body protein, which is burned as an energy
ent dense) is to recommend a plant-based diet. In source when dietan carbohydrate is low. One class
general, plants (fruits, vegetables, whole grains, of dietary carbohydrate, fiber, is largely indigestible,
nuts, seeds, herbs, and spices) are high in vitamins, and as such, helps lower the risk of heart disease
minerals, fiber, and phytochemicals; low in fat, cho (by increasing the excretion of cholesterol); it is
lesterol, sodium, and calories; and associated with also associated with improved bowel function.4
a reduced incidence of many types of cancers and When carbohydrate sources are refined to produce
diseases common to cancer survivors." micronutrient-deficient sugars (e.g., white and
brown sugars and com sweeteners), these are often
consumed in lieu of more nutritious choices. Food
Carbohydrate, Protein, products made with refined sugars, particularly
and Fat soft drinks and other sugar-sweetened beverages,
Macronutrients—the protein, carbohydrate, and can add substantially to a diets energy level, pro
fat components of diet一are essential dietary moting weight gain and thus adversely affecting
constituents that provide fuel or energy. (One the outcomes of many cancers.4 Recommended
other dietary component_the alcohol in alcoholic nutrient-dense foods rich in carbohydrate include
products——provider calories; hwHTver, alcoholic fruits, vegetables, whole grains, and low-fat milk
beverages have little nutritional value and also may (the latter three are sources of both carbohydrate
stimulate appetite). Weight gains or losses result and protein, with low-fat dairy products serving as
from consuming too many or too few calories, but the richest protein source of the three).
maintenance of a weight within the healthy range Protein plays fundamental structural and
does not uniquely indicate optimal nutrition status. functional roles in all body cells. It acts in cellular
A woman needing 1,450 calories to support a desir signaling, drives reaction response rates, and plays
able weight of 125 pounds (57 kg) could consume key roles in immune and cellular function, affecting
those calories as sugar (carbohydrate), gehtin (pro
tein), and butter (fat) to maintain that weight. Then
義
again, with that diet, her micronutrient (vitamin Take-Home Message
and mineral) profile, and thus her health status/ Ftness professionals can use
would be quite poor. Indeed, a diet that derives an empty carbonated bever
macronutrients from fruits, vegetables, and whole age can to demonstrate how
grain breads and cereals (carbohydrate); lean sugar can add up: a 12-ounce
meat, poultry, and fish (protein); and nuts, seeds, (360 ml) drink containing 39 grams (or 9.3
avocados, and olive or canola oil (fat) also would teaspoons) of sugar also contains 156 cak
include necessary micronutrients and would thus ories. Over a year, this adds up Io 56.940
be far superior. calories―enough fuel to support 16 pounds
Eating a wide variety of nutrient-dense foods (Z3 kg) of body weight. They can ask their
allows all nutrients to work synergistically to patients: Is this a healthy (nutnent-dense)
help prevent cancer development, disease recur way to fuel those tissues?
rence, and the occurrence of comorbidities, and
both normal and cancer cells. Because many high- for CVD and a lower overall mortality rate.4 High
protrin foods contain large amounts of saturated intakes of omega-6 fatty acids (fcnxl sources include
fat, cancer patients should select lower-saturated- com, cottonseed, and safflower oils, as well as prod
fat protein-rich foods (e.g" lean meat, fish, low-fat ucts containing these oils, such as cookies, crackers,
milk products, eggs, legumes, nuts, and seeds) to snack foods, and salad dressings) interfere with
best achieve a heart-healthy diet Adequate protein the conversion of plant-based amega-3 fatty acids
intake becomes critical for the cancer patient expe into their more active forms (eicosapentaenoic acid
riencing tissue destruction as a result of surgery, and docosahexaenotc acid), as well as the overall
chemotherapy, or radiation therapy, particularly metabolism of these fats. It is believed that humans
when these treatments are complicated by diar evolved on a diet containing a 1:1 ratio of omega-6
rhea or malabsorption/ The following guidelines to omega*3 essential fatty acids, whereas the U.S.
can help estimate protein requirements for cancer current ratio is between 15:1 and 16.7:l.w Thus,
patients:” there is concern about the potential health risks of
the present-day dietary pattern.
Normal or maintenance needs 03-1.0 g/kgof
body weight Current IOM recommendations for fat intake
include limits on saturated fats (<10% of energy)
Nonstrvsscd cancvr patients 1.0-1.2 g/k次 of
body weight and the elimination of trans fats (i.e.z fats that
are formed during the hydrogenation process of
Severely stressed cancer patients l_5-2.5g/kgof
body weight unsaturated vegetable oils, so as tp hnprove shelf
life, transform liquid oils into solid margarines
Inconclusive evidence highlighted by the recent and shortenings, or enhance the texture of baked
completion of two large clinical trials suggests that products).*,n, Healthy fat-containing food choices
total fat consumption affects cancer outcomes. include nuts, seeds, wheat germ, avocados, olive
The Women’s Healthy Eating and Living (WHEL) oil, and fatty fish. However, patients may need
study tested a diet low in fat and high in fruits, to be advised tiut although these foods provide
vegetables, and fiber againft usual care in breast essential nutrients, they also provide many calories;
cancer survivors followed over seven years * No therefore, judicious use is recommended.
differences were observed in either disease-free
or overall survival; however, these findings have
been attributed to high baseline fruit and vegetable
intakes in both study arms, as well as an absence of Take-Home Message
weight lops, despite following the low-energy diet' Atness professionals should
In contrast, findings of the Women’s Intervention teach their clients a simple way
Nutrition Study (WINS) differ markedly. In this trial to choose healthier lats. They
of 2,437 breast cancer survivors followed for five should reduce saturated fat
years, the dietary interv ention was focused solely intake by limiting animal*based fats (e.g.t
on dietary fat rrstrictkm (il 5% of energy) and tested those found in meats, milk, cheeses) and
against a healthy diet* A significantly reduced risk solid tats, and eat moderate amounts of
of recurrence, which was of even greater magnitude monounsaturated fats by choosing plant
in women with estrogen-rverptor-negative breast based fats that, when punfied, are typicaty
cancer, was observed in the km，-fat group. How liquids or oils. Canola and olive oils are good
ler, the findin주 may have been confounded by the choices.
6-pound (2.7 kg) weight loss observed within this
same group over the course of the study (reinforcing
the importance of weight control as a key lifestyle
factor in cancer survivors》.*7
Fad Diets
Preliminary data suggest that foods high in Carbohydrate restriction, as proposed by the Atkins
omega-3 fatty acids (e.g.r fish and walnuts) may diet and other spin-offs in the popular press, may
help with cachexia and enhance the effects of some promote weight loss at least in the short term, but
treatments, and are associated with a reduced risk their long-term effects are unknown, particularly
in cancer survivors.101 The best available data on concerned about overeating, however, juices do
successful and long-term weight k)s« indicate that not match the satiety value of whole fruits and
a relatively low-fat, low-calorie diet is the optimal vegetables; additionally, when large juice servings
approach to healthy weight management and are consumed, excess calories can contribute to
should be, of ccmitm?, combined with regular exercise weight gain. Only 100% juices should be chosen一
and behavior modification.2M iaL w This prescription added sugars detract from the nutrient density of
for weight management is currently endorsed by any beverage.
every U.S. health organization, including the Ameri
can Cancer Society, American Institute for Cancer Pesticides
Research, World Cancer Research Fund, American The use of pesticides and herbicides has increased
Dietetics Association, American Heart Association, tremendously since the 1940s, and although many
Centers for Disease Control, and American Diabetes have been phased out, their residues may still be
Association. in foods eaten today.' There is no epidemiological
evidence that current exposure jex els cause cancer/
Fruits and Vegetables but for those interested in a cautionary approach,
fruits and v egetables may be peeled or washed in
Because fruits and vegetables arv loaded with both
lemon juice or vinegar baths to reduce residual sur
fiber and water, they enhance satiety, are low in
face pesticides. The Environmental Working Group
calories, and may promote healthy weight man
(EWG), a research and advxxacy organization basexi
agement. Fruits and vegetables contain multiple
in Washii^tofi, D.C., has identified -Dirty Dozen**
nutrients and phytochemicals related to cancer
fruits and vegetables (pean, apples, bell peppers,
reduction, and although it is not yet known which
celeryêctarinfs, strawberries, cherries, kale, let
combination provides the best protection, the US.
tuce, and imported grapes and carrots), which may
Centers for Disease Control and Prevention, along
have comparatively higher pesticide residues than
with the Department of Health and Human Services
other fruits and vegetables; as d result, cim»uiners
and the National Cancer Institute, recommend at
are advised to buy those raised organically. In con
least seven daily servings for women and nine for
men- ▲ 7 trast, they deem the “Clean 15° (onions, avocados,
Fresh, frozen, and canned fruits and vegetables sweet com, pineapples, mangp鑛, asparagus, sweet
can all be nutrient-dense food choices. Fresh pro peas, kiwi, cabbage, eggplant papaya, watermelon,
duce typically has the greatest nutritional value, broccoli, tomatoes, and sweet potatoes) to be rela
but long periods in transit, in grocery stores, and tively free of pesticide residues. Given shifting pat
on home shelves all contribute to nutrient loss. For terns in agriculture and large-scale buying in the
this reason, produce frozen immediately after har free market, it i$ unknown whether these categori
vest may contain more nutrients than some fresh zations will to those seeking to minimize
produce. Canning and drying processes reduce their exposure to pesticides over the long term.
heat-sensitive and walrr-solublc nutrient content
although foods preserved with these methods may
Organic Foods
pose less of an infection risk for patients undergo The term organic commonly refers to plant foods
ing immuimsupprcssive cancer treatment.* Immu* grown without pesticides or genetic modifica
nosuppressed patients also should avoid eating tions, or to meat, poultry, and dairy products from
unpeeled raw fruits or vegetables because thry animals raised without antibiotics or growth hor-
may contain pathogens, which are destroyed in fmmes.4 The FDA sets limits for produce exposure to
the cooking process. In terms of cooking methods, agricultural chemicals, but as stated previously, it is
microwaving and steaming, instead of boiling, unknown whether the choice of organic versus inor
avoids nutrient losses that occur when nutrients ganic fiKMis influence* cancer incidence, rtycurrence,
leach into cooking water that is then discarded. or progression.4 With regard to nutrient quality, a
Juicing provides a means for increasing fruit recent 50-year systematic literature review found no
and vegetable intake, particularly for those who difference between organically and conventionally
have difficulty chewing or swallowing. For those produced foodstuffs.105
Whole Grains meats (those preserved by smoking, curing, salting,

or adding preservatives》have been convincingly
Whole grains, rich in antioxidants and biologi linked to colorectal cancers.'
cally active compounds, may reduce the risk and Compared to animal protein sources, plant-based
progression of cancer. *• In refined grains both the sources (bean、lentil、peas) have low-saturated-
bran and germ are removed during the milling pro fat and high-phytochemical profiles. There is one
cess, along with other key nutrients, which lessens caveat, however: Soybean products contain notable
their protective qualities. In the United State most cocKentratitins of phytoestrogens, which can mimic
refined grains are enriched to ensure that certain B biological hormones; their effect on female can
vitamins and iron are added back after milling (a cers is still under debate. For this reason, experts
legal requirement). Unfortunately, most of the lost nxonunend that people consume soy in rruxierate
nutrients are not replenished through enrichment, amounts <mly-no more than three daily servings.4
nor is fiber.1® For this reason, people should choose
prxxiucts whose first label ingredient is a whole
grain (e.g., brown rice, bulgur, wheat germ, graham
Food Safety
flour, whole grain com, oatmeal, popcorn, peari Certain cancer treatment regimens, especially those
barley, whole oats, whole rye, or whole wheat). Note involving chemotherapy, can induce immunosup-
that color alone can be misleading, bemuse many pression, which makes people susceptible to infec
grain products add caramel coloring to mimic the tions. For this reason, food safety* is of particular
appearance of whole grain pnxjnctN. concern. AU surfaces and implements (including
hands) used in food preparation should be thor
Meats and Meat Substitutes oughly cleaned, with particular care given to wash
ing surfaces, tools, and sponges that come in contact
Lean meats provide valuable nutrients, particu with raw meats. Cancer patients should cook meats
larly protein, zinc, iron, and vitamins Bk and Bir and eggs thoroughly and store all foods promptly at
Although the iron from red meat (beef, lamb, goat, low temperatures to minimize bacterial growth. In
and pork) is absorbed more readily than the iron restaurants, foods that may be contaminated with
from plant sources or supplements, eating red meat bacteria (e.g., sushi, undercooked meats, food in
may increase the formation of N-nitroso compounds sahd bars) should be avoided, especially during
that are linked to the development of colon cancer? times of active treatment.
Carcinogens, such as heterocyclic amines and pdy-
cydk aromatic hydrocarbons, can be generated by
cooking meats at high temperatures or by broiling
Nutrition Biomarkers
or charbroiling over a direct flame.' Processed Biomarkers are substances identified and monitored
in body fluids or tissues that allow an assessment
of the incidence or biological behavior of a disease,
or the health status of the person.,a,-n" Registered
多
Take-Home Message dietitians evaluate a host of nutrition-related bio
Although large meat portions markers, including the following:
are commonly consumed in the
United States and other industri* • Creatinine height index, nitrogen balance, and
aiized nations, an ample protein albumin and pre-albumin levels as markers of
amcxjnt for most adults is two 2- to 3-ounce protein status
(60 to 90 g) meat servings per day. A one- • C-reactive protein as an indicator of inflamma
finger-sized portion of meat is equivalent to tion and increased stress-related nutrition risk
1 ounce (30 g). Using this rule of thumb to • Delayed cutaneous hypersensitivity and totaI
monitor meat intake is a good way to monitor lymphocyte count to evaludte immunocom
exposure to meat carcinogens. A vegan diet petence
offers another avenue for reducing exposure • Hematocrit, hemoglcibin, and mean corpus,
to the carcnogens contained in meat cular volume as determinants of vitamin and
mineral status
• Serum \*itamin D or vitamin Bl2 lev*els to exam loss (e.g” hormonal therapies such as glucocorti
ine respective vitamin status coids; gonadotropin- releasing hormone agonists;
androgen deprivation therapy for prostate cancer;
Although laboratory tests are available for assess
certain chemotherapies such as methotrexate,
ing most vitamins and mineral levels in a person,
cyclophosphamide, and fluorouracil for breast
many of these tests are cost prohibitive and not
cancer; thyroid-stimulating hormone suppressive
routinely performed in the clinical setting.72 Com
therapy).,D_,,s As a result osteopenia, osteoporo
mercial laboratories advertise nutritional assess*
sis, and increased fracture rate have been found
ment via hair, saliva, or toenail analysis; however,
in survivors of a wide range of cancer: breast,
with few exceptions (e.g.# certain metals in toenails),
prostate, testicular, thyrgid, gastric, and central
these compounds are not substantiated indicators of
nervous system cancen, as well as non-Hodgkin's
nutritional status. Clinical Laboratory Improvement
lymphoma, many hematologic malignancies, and
Amendment (CLIA)-<ertified facilities are reliable childhood cancers.에1*
resources for nutrient assessments. The goals for patient care include early identifica-
ti«i of those at high risk for osteoporosis, as well
Water and Hydration as prevention of fractures in patients with docu
mented bone deterioration. To address these goals,
Body water content declines with age as a result of
the American Society of Clinical Oncology advises
both reduced activity and reduced lean body mass.
bascliiu* bone density assessment with continued
Dehydration can easily occur among cancer patients
monitoring and pharmacological treatment based
undergoing chemotherapy or radiation treatments一
on bone density findings.121 Fitness professionals
particuhrly those who have suffered damage to
can take a proactive stance in reducing bone loss,
the esophagus, stomach, or intestines. Drinking
not only by advocating weight bearing and resis
sufficient fluids becomes difficult when radiation
tance training exercise, but also by being aware of
to the head or neck elicits pain and inflamontion in
risk factors： smoking, excessive alcohol intake, low
the mouth, throat, and esophagus.'3 Other common
BMI, and poor diet.l2',M Although the importance
cancer treatment-related side effects associated with
of adequate calcium (800 to 1,500 mg/day) and
inadequate hydration are fatigue, light-headedness,
vitamin D (400 to 600 lU/day) in bone formation
and nausea.4 The thirst mechantom is not always a
is well established, a nutrient-dense diet (of which
reliable indicator of fluid needs, particularly in the
low-fat dairy products are only one part) offers
elderly, who cwnprise the majority of cancer patients
other important contributors to bene health.121, m
(60% of people with cancer art at least 65 years old).1*
Excessive caffeine, sodium, protein, or supplemen
For this reason, fitness ptofessionals should regulariv
tal vitamin A intake may negatively affect calcium
inquire after their clients for signs of dehydration
abM>rpticm and bone tunurver"公 m
(e.g., dark yellow urine, reduced urination, dry
mouth, or rapid weight loss). The following guide
lines can help clients estimate their fluid needs:71 **
Take-Home Message
Maintenance: 30-35 ml/kg of body weight
The percentage of tat noted on
During cancer tTvatmcnt: 1 ml fluid per calorie cC
milk labels can be misleading.
estimated energy needs Although "2% milk" may imply a
small amount of fat, this number
Calcium, Vitamin D, refers to the percentage of weight that com
and Osteoporosis prises fat. Practitioners should let ttieir pa
tients know that 2% milk derives 36% of its
Osteoporosis commonly affects healthy adults over calories from fat. whereas 1% miNc derives
age 50 (one third of American women, one fourth 21% of its calories from tat. Nonfat milk is
of American men); thus, it should not be surpris the real 2% milk_only 2% of its calories are
ing that a substantial number of cancer patients from fat. Also, because mrik fat is an animal
have osteoporosis at the time of diagnosis.111 IU tat, ifs best to reduce the amount consumed.
Various cancer treatments further compromise bone
Establishing recommendations for vitamin D cancer survivors use some form of CAM therapy,
intake is complicated for the following reasons： with 69% reporting a belief that such therapies will
prevent recurrence and 25% holding the conviction
• Exposure to sunlight, not dietary intake,
that they will offer cure.1*-1* Nutritional CAM
is the major source of vitamin D for most
people?27 and the ability to differentiate oral therapies include dietary modification; herbal
vitamin D intake from that made endog preparations; vitamin and mineral therapy; and
enously (25-hydroxyvitamin D |25(OH)D)) metabolic treatments for detoxification, fasting, and
is limited.12" rejuvenation.,M Little solid data exist to support
• Food and supplement database values used to these methods as cancer treatments. Nevertheless,
assess dietary intakes show excessive variabil it is important to recognize that CAM treatments
ity causing difficulties in quantifying current may meet emotional, social, or spiritual needs
intakes.**-1® that remain unaddressed in conventional clinical
• Dose-response relationships are difficult to practices.72 By the same token, sume forms of CAM
measure due to variations in serum 25(OH)D treatments may be associated with significant side
assessment techniques compounded by fluc- effects. Fitness professionals should openly discuss
tuations in serum levels with respect to study CAM treatments with their patients and point them
locations latitude) and time (seasonality to reputable source* of information (e.g., the U.S.
affects the amount of sunlight received).12*
National Institutes of Health's Office of Comple
• Most available data looking at intake dose mentary and AMvmativv Medicine at http://nccam.
response and serum 25(OH)D concentration
nih.gov乂
were drawn from studies designed to measure
a single outcome in a specific population
(i.e., bone health in white postmenopausal Functional Foods
women)?31
Functional foods include conventional foods
Symptoms of overt vitamin D deficiency (i.e., and modified foods《i.e., fortified, enriched, or
deep bone and muscle pain) are seen with serum enhanced) that may reduce disease risk, promote
25(OH)D values <20 nmol/L, whereas subclinicri optimal health, or both.137 Tomatoes and tomato
deficiency lewis (i.e., thewe affecting general ccUular products arc examples of conventional food» that
function but not bone mineralization) are highly have been linked to reduced risk for prostate, ovar
controversial with suggested levels ranging from ian, gastric, and pancreatic cancers; and consuming
275 h> 100 nmol/L.IM Serum 25(OH，D levels >75 orange juice that ha포 bevn functionally modified
nmol/L have been proposed to maximize health with the addition Of calcium may reduce the risk
benefits.1分,132 Dietary recommendations for adults for colorectal cancer? **
31 to 50 years of age are 200 J(J per day (for 51 to Manufacturer* determine how their functional
70 years, 400IU; >70 years, 600IU)?® Until further food products will be regulated (i.e.# as a conven
evidence is available； high-dosage supplements tional food, food additive, dietary supplement,
are not recommended unless blood tests indicate drug, medical food, or special dietary f<x>d) when
an inadequacy. they write package label claims. These claims deter
mine the quantity and quality of science needed to
support their purporteid health benefits, which can
Complementary lead to confusion over which products are truly of
Alternative Medicine value.157 Although research on myriad functional

foods is ongoing, and definitive findings and con
and Functi에al Foods sensus are likely decades away, fitness profession
als can play it safe by recommending a diet that
Complementary and alternative medicine (CAM) contains a variety of conventional plant foods that
refers to the various medical, health, and lifestyle tend to be rich sources of a variety of anticancer con
practices and therapies not traditionally part of stituents, such as salicylates, phytostrrols, Mponirm,
conventional medicine. 135 Approximately 90% glucosinolates, polyphenols, protease inhibitors,
of cancer patients and up to two thirds of adult phytoestrogens, sulphides, terpenes, and lectins?
Alternative Dietary Therapies drugs, which effectively frees manufacturers from

having to demonstrate product safety or effective
The belief that specific diets can cure cancer has ness. Little evidence suggests that supplements are
led to the growth of alternative dietary therapies,
beneficial for cancer treatment or survival, and a
typically amsisting of vegetable-based or ^natural* growing number of studies demonstrate harm.,4M
diets shored up with dietary supplements of mostly
Certainly, supplements are warranted when
unproven value.139140 Of these, the macrobiotic diet
specific risks or deficiencies have been medically
is most commonly chosen for cancer treatment
identified; unfortunately, problems can arise when
although the Gerson diet also is popular among
patients choose to self-medicate with vitamins or
adult cancer patients.4-140 The macrobiotic diet was
minerals. For example, for the prevention of neural
originally prop<v«cd asaZen-rdated spiritual climb
tube defects in offspring, folic acid supplements
culminating in a brown rice and water therapy
are prophvlactically recommended for women of
promoted as a cancer cure.141 In the 1960s, Michio
childbearing age; however, these same supplements
Kushi popularized the diet in the United States and
are contraindicated for patients receiving certain
adapted it to include mostly whole cereal grains and
fohte antagonist chemotherapies (e.g., capedtabine,
vegetables, supplemented with smaller amounts
5-fluorouracil, and methotrexate).190 Although
of bean products and sea vegetables, while realm
low-dose multivitamins are generally considered
mending avoidance of conventional therapy."1
to pose minimal risk, cancer patients should avoid
Although a well-planned macrobiotic diet may be
high-dose supplement!* until the rvlated effects on
able to meet nutritional needs, special attention is
chemo- or radiation therapies have been medically
needed to ensure that protein, vitamin caldum,
evaluated.
and fluid requirements are met especially during
In light of thine data, it is important to reiterate
times of treatment when nutrient needs may be that both the XcS and the WCRF/A1CR recom
increased?39-141
mend foods rather than supplements as sources of
The Gerson diet was first proposed by a German
nutrient유. Thus, fitness pn)fe«sionaU can provide
physician to treat tuberculosis, and he later admin
much-needed guidance in pointing clients to foods
istered it as a treatment for cancer and other dis-
that are safer, and perhaps more effective, sources
eases.,> u, The diet purports to *detoxif)'■’ the body
of nutrients (sec table 7.4》. This is a considerable
with sodium and fat restrictions, enemas, and poU>
task given that the majority of canoer survivors (60
sium supplements, as well as hourly consumptions
to 80%) report supplement use. \
of raw vegetable-based foods，and supplements of
iodine, vitamin Bu, thyroid extracts, and pancreatic
enzymes.Many proponents of the Gerson
diet advocate its use in lieu oi other scientifically Alcohol _______
established cancer therapies, which causes ob\i-
Alcohol intake increases the risk for cancers of
ous concern. Reviews by both the National Cancer
the mouth, pharynx, larynx, esophagus, liver, and
Institute and the American Cancer Society have
breast; and beer is linked to colon cancer.1 During
found no evidence tiiat the Gerson diet is of benefit
treatment for head and neck cancer, continued
in controlling cancer; in fact it is associated with
alcohpl ronsumption is related to higher rates of
several nutritiocwi! problems.4
complication and poorer survival rates; alcohol also
exacerbates treatment-related oral mucositis in a
Dietary Supplements variety of patient subgroups. A recent epidemiologi

cal review of alcohol intake in more than 1 million
Limits to the US. Food and Drug Administration women suggests that low to moderate consumption
(FDA广s ability to regulate dietary supplements increases the risk of certain cancers (i.e., breast,
(e.g., vitamins, minerals, amino acids, herbs) were mouth, pharynx, larynx, esophagus, rectum, and
established in 1994 with the passage of the Dietary liver), but decreases the risk of others (thyroid and
Supplement Health and Education Act?® This act renal cell cancer, and non-Hodgkin's lymphoma).1,1
allows concentrated nutrient and herbal doses (e.g., From a nutritional standpoint, alcohol is a
pills or powders) to be classified as foods rather than nutrient-poor, calorie-dense beverage that potentially
TABLE 7.4 Nutrient-Dense Food Sources for Selected Food Components

Examples of nutrient-dense food sources
Nutrients
Macronutrients
Carbohydrate Fruits, vegetables, low-fat milk products, whole grains
Protein Lean meats and pouttry, low-fat mik and milk products, legumes (beans, peas), nuts
Fat Avocados, nuts, seeds, wheat germ, cold water fish (salmon, mackerel, etc.)
Vitamins
Vitamin C Citrus fruits, broccoli, strawberries, tomatoes, dark leafy greens, papayas, peppers
Vitamin D Fish, fortified milk or ready-to-eat cereal, eggs, mushrooms
Vitamin E Almonds, pistachios, sunflower seeds, hazelnuts, peanuts, broccoli, spinach
Foiate/folic acid Dark leafy greens, fruits, dried beans and peas, fortified grain products (including
ready-to-eat cereals)
Minerals
Selenium Brazil nuts, tuna, beef, cod. turkey, enriched pasta, eggs, brown rice
Calcium Low-fat mik, cheese, and yogurt; dark leafy greens: sardines
Magnesium Nuts and seeds (pumpkin seeds, almonds, soy nuts, cashews, peanuts, etc.), tofu,
beans, oatmeal, spinach, dairy foods
Iron Clams, meats, legumes, lentils, spinach, ready-to-eat cereals, enriched grain
products, raisins and other dried fruit
Potassium Bananas, oranges, avocados, apricots, sweet potatoes
Fiber
Bran, beans, peas, whole grains, strawberries, pears, dark leafy greens
Phytochemicals
Isothiocyanates Cabbage, broccoli, cauliflower, kale
Isoflavones Soy products
Lutein Yellow and orange fruits and vegetables, dark leafy greens
Lycopene Tomatoes, tomato products, watermekxis, pink grapefruits, apricots, guavas
Phenolic adds Tomatoes, citrus fruits, strawberries, raspberries, carrots, whole grains, nuts
Polyphenols Green tea. grapes, wine
Quercetin Apples, green and black tea, onions, raspberries, red grapes, citrus fruits, dark leafy
greens, cherries, broccoli
Terpenes Cherries, citrus fruit peel
、
Comp«，d front Intormanon ir)Wt_r ey and Roflee', 200' and WCRF/AiCR?
contributes to weight management problems and not be encouraged to initiate alcohol intake if they
may increase the burden on the liver because it do not already drink; however, for those free from
necessitates metabolism via detoxification path akohol-associated cancers, recommendations sug
ways. On the other hand, when consumed in gest limiting intake to fewer than two drinks per
moderation, alcohol’s cardioprotective effects day for men and one drink per day for women.4,
could benefit some cancer survivors, particularly 1Fitness professionals should advise clients to
those who are at high risk for CVD (e.g., men with consult with their physicians for guidance related
prostate cancer). Certainly, cancer sunivors should to the appropriateness of alcohol use.
Summary TL. Osteoporosis and rate of bone loss among post-

mcnopawuil »ur>ivors of brvast cancrr. Cancrr. 2005;
104 1520-1530.
Being adequately nourished is important for every,
9. Fouad MN, Mayo CE Funkhouser EM, Irene Hall
one, but it is even more important for patients who H, Urban DA, KiHc CI. Comorbidity independently
are undergoing active cancer treatment and for sur predicted death in older prostate cancer patients,
vivors who seek optimal health and well-being after more of whom died with than from their disease. /
diagnosis and treatment. Fitness professionals can Clin Eptdemiol 2004; 57: 721-729.
play a key role in detecting nutritional issues, inter 10. Herman DR, Ganz PA, IMursen L, Grvendale GA.
vening as appropriate, and referring clients needing Obesity and cardiovascular risk factors in younger
more specialized care to registered dietitians. In breast cancer survh ors: Thtf Cancer and Mcnopju»?
Study (CAMS). Brmst Cancer Res Tnat. 2005; 93： 13»23.
addition, they also can play a key role in reinforc
ing appropriate nutritional recommendations and 11. Jemal A, Clegg LX, Ward E, Ries LA, Wu X, Jamison
PM, Wingo PA. H0v\rc HL, Anderson RN, Edwards
motivating clients to adhere to guidelines. Given
BK. Annual report to the nation on thv »UtU3> of
the interaction and synergy between exercise and cancer. 1875-2(X)1, with a special feature regarding
diet in governing key issues such as energy balance surviva^Mcrr. 2004; 101： 3-27.
and overall health, fitness prcifesskinals can play an 1Z KeWhdmdji M, Kuo Y-F, Shahinian VB, Gixidwin, JS.
important role in providing sound dietary guidance. CattM! of death in older men after the diagnosis of
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CHAPTER 8j
Health Behavior
Change Counseling
Karen Basen-Engquist, PhD, MPH, Heidi Perkins, PhD, and Daniel C. Hughes, PhD
following:
• Knowledge to identity a teachable moment for cancer survivors and ability to use that time
to provide appropnate information and education about resuming oc adopting an exercise
program, k
• General knowledge of psycho-social problems common to cancer survivors, such as

【depression, anxiety, fear of recurrence, sleep disturbances, body image, sexual dysfunction,
and work and marital difficulties.
• Knowledge of behavioral strategies that can enhance motivation and adherence (e.g.. goal
setting, exercise logs, planning).
• Knowledge of the impact o< cancer diagnosis and treatment on quality of lile (QOL), and the
potential for exercise to enhance a range of OOL outcomes for survivors (e.g., sleep, fatigue,
and other factors).
• Knowledge of and ability to determine effectiveness of group exercise programmng vs.
individual exercise to meet client's needs.
• Knowledge of how cancer and cancer treatment relate to ability and readiness to start an
exercise program.
• Ability to facilitate the social support needs that are cancer specific including connections to
websites and local suppon groups.
141
142 ACSM's Guide to Exercise and Cancer Survivorship www.acsm乂)r玄
Evidence of the benefits of exercise for cancer least fatigued, and emphasizing the benefits. Often,
survivors is growing. Nevertheless, many cancer encouraging participants to focus on simply starting
surxivors are not physically active, or they embark a scheduled session instead how long they need
on an exercise program but lapse back into a sed to exercise promotes incieased activity. For clients
entary lifestyle. Cancer survivors may have unique with fatigue, fitnc» pmfessuwials should ackncnvl-
barriers to adopting an exercise program because edge that the first minute is always the hardest, but
of disease- or treatment-related side effects and just getting started is the most important thing? h
sequelae. However, research on exercise adoption Cancer patients and survivors, particularly those
and maintenance shows that the use of behavioral who have received chemotherapy or immune-
theory and individually tailored messages can modulating treatments such as interferon, often
increase the probability that cancer survivors will report that the treatment has interfered with cog-
increase their activity and stay active. This chapter nittve function. Survivors often refer to tiiis as
describes the psychological and behavioral effects chemo-brain and liken it to being in a mental fog.
of cancer diagnosis and treatment, and how they Most frequently, the severity of these deficits are
affect a client’s willingness to begin exercise along mild,7 and except in the case of people who have had
with long-term adherence to an exercise program. radical treatments to the central nervous system,
these cognitive problems are unlikely to affect the
physical ability to exercise. Studies of exercise in
Effect of Cancer on the elderly, which provide e% idence for associations
between physical activity and cognitive function/
Readiness tojxercise have led other researchers to speculate that exercise
may ameliorate cognitive dysfunction related to
Despite the benefits ot exercise for cancer survivors, cancer treatment as well. This topic has not been
aspects of the cancer experience may stand in the well studied, nor has the effect of cancer patients'
way of starting an exercise program or resum and survivors* cognitive function on exercise
ing exercise after a cancer diagnosis. This section adherence. It is possible that clients with cognitive
describes common sequelae of cancer that can problems may have more difficulty making time for
interfere with survivors, ability or moth'ation to exercise, because their other daily tasks take longer
exercise. Fatigue, diminished cognitive function, or they have more difficulty in organizing their time.
sleep dysfunction, psychological distress, and fear They may also have difficulty remembering exercise
of lymphedema have all been cited as barriers to rvaxnmmdaticins and prescriptions. Assisting such
clients with time management and providing writ
Fatigue is a common side effect of several cancer ten and pictorial instructions for all exercises, may
treatment modalities, and for many survivors support their exercise adherenev. In addition, it may
fatigue continues after treatment ends. Studies be important to focus on the enjoyment of an activity
estimate that 30 to 60% of cancer survivors have lin versus detailed goal setting or progression plans.
gering moderate to severe fatigue after treatment.1 Sleep dysfunction is one of the most common
Not only is fatigue common, but it seems to have problems reported by cancer patients and survi
a larger effect than other symptoms on patient and vors, particularly those who are in acth e treatment.
survivor quality of life.1 * The causes of fatigue are Symptoms and side effects such as pain and anxiety
multidimensional, but physical deconditioning and may exacerbate the sleep problems. In particular,
increased levels of proinflammatory cytokines are survivors on hormonal therapy or whose treatment
both potential mechanisms. has interfered with hormonal functioning often
Exercise can ameliorate cancer-related fatigue/ experience vasomotor symptoms (hot flashes) that
but motivating people with fatigue to exercise is interfere with sleep.* 11 Sleep problems can affect
problematic. Helpful strategies with this popula multiple dimensions of a person's life, and may
tion may include choosing activity that is highly exacerbate cognitive functioning problems, fatigue,
valued by the client, starting with brief bouts of and psychological distress. Clients reporting symp
exercise done throughout the day, scheduling exer toms of a sleep disorder such as sleep apnea (symp
cise during times of the day when people are the toms are loud snorings pauses in snoring followed
Health Behavior Change Counseling 143
by gasping or choking noises, daytime tiredness), distress may be more satient for cancer survivors.
should sec a physician for a referral to a sleep spe For example, fear and anxiety about recurrence is
cialist. Those with problems with insomnia should particularly common, and is usually most promi
exercise early in the day, avoid naps, pass up caf nent preceding medical appointments. Fitness
feine Late in the day, and consider some restorative professionals should bt* Nensitive to clivnts in times
mind-body activity before bed, such as gentle yoga. of heightened distress, and practice active listening
skills (see the sidebar Active Listening Skills for Fit
ness Professionals) rather than reassure clients that
Mevery仕ung will be all rightM In addition, clients
，흑象 Take-Home Message should be encouraged to continue their exercise
자■[ Cancer patients and survivors program during these times, given that moderate
may have specific barriers to activity is associated with reduced anxiety and
beginning and maintaining an improved perceived energy,K K14 and may relieve
exercise program that are less depressive symptoms.*' u
common in people who have not had can Distress related to appearance changes is also
cer. They may experience fatigue, distress, common, both for pa bents under active treatment
or difficulties with cognitive functioning and and for survivors. Most chemotherapy patients lose
sleep. Such problems may require adapta their hair, not just on their heads, but also eyebrows,
tions to the exercise program or the teaching eyelashes, hair on the arms and legs, and pubic
approach, such as doing exerase in multiple hair. Other appearance issues include surgeries
short bouts if fatigue is an issue. that cause disfigurement (e.g., mastectomy, limb
amputations, Facial surgeries or radiabon), chemo
therapy agents that cause rashes, and weight loss
The diagnosis of cancer and the continuum of or gain. Some patients are very self-conscious about
the cancer experience can be extremely distress, the appearance changes and may be unaimfortable
ing. Psychological distress tends to be highest exercising in public, particularly when wearing
shortly after diagnosis and in the early phases of revealing clothing. These participants may be more
treatment, with gradual improvement over time. comfortable exercising in private jsettings until they
Approximately 24 to 33% of oncology outpatients feel more comfortable.
screen positive for psychological distress,12 but stud Fitness professionals can also promote a positive
ies comparing long-term cancer survivors with the body image by encouraging clients to talk with
general population often show no increased risk people they trust about their feelings and experi
of psychological distress, particularly at clinical ences with regard to physical changes. They can
leveb, in cancer survivors?* Although much of the help them understand that distress about appear
distress associated with cancer seems to dissipate ance changes is normal, but that withdrawing from
over time, some times, events, and specific areas of others is not a healthy response. Clients can be
-------------- 、
Active Listening Skills for Fitness Professionals
• Watch for the verbal and nonverbal content of the client's message.
• Demonstrate interest through nonverbal behaviors such as facing the client, maintaining eye
contact nodding, and maintaining an open posture.
• Avoid thinking atxxjt a response while the client is talking; attend carefully to what he is saying.
• Ask questions to allow the client to express her feelings. Listen rather than interpret or evaluate
what the client is saying.
• Paraphrase what the client has said to verify the content of the message.
encouraged to reflect on aspects of their appearance health and may be open to making changes such as
that they likr and enjoy, rather than focusing on the adopting an exercise program. Surveys of cancer
negatives. The cancer experience may make some survivors reveal that approximately one quarter
participants want to work out in more private set to one third report increases in physical activity
tings, whereas others will want to exercise in group following a cancer diagnosis.Recognizing the
settings because they are seeking the social connec potential for increased motivation for behavior
tion. Either approach can be effective. Feelings will change after a cancer diagnosis can help fitness
vary among clients and may also change over time pnêssionals keep clients focused on exercise gpaht.
for any given client.
Survivors who have had treatment (e.g.z lymph
node removal, radiotherapy) that puts them at risk
for lymphedema may be very fearful about this
Theory-Based Methods
side effect, which can interfere with their exercise. and Exercise
Exercise recommendations for survivors at risk
for lymphedema are provided in chapter 6, but There are several advantages to understanding
what bears mention here is that data on causes and and applying behavioral theory when promoting
mechanisms of lymphedema are just beginning to exercise in cancer patients and survivors. !n the
emerge. Although survivors have often received general population, programs to increase physical
(and may continue to receive) medical advice to activity or exercise behavior have been shown to
avoid exerting the affected limb to prevent poten- be more effective when grounded in behavioral
tial injury and increasing the risk of lymphedema, theory. Furthermore, knowledge of these theories
this recommendation is not solidly backed by evi helps fitness professionals encourage clients to
dence. We are now learning that exercise, property start and maintain their exercise programs. Three
executed, may even decrease flare-ups in women theories, or models, that have been successfully
with breast cancer who have IvmphedaBi.17 The applied to exercise settings are social cognitive
key is properly executed exercise. Nevertheless, theory, the theory of phimed behavior, and the
many survivors harbor fears about lymfhedema， trans theoretical model.
and thestf fears may interfere with their exercise
adherence. Fitness professionals should follow the Social Cognitive Theory
recommendations in chapter 6 and be cognizant of
Social cognitive theory (SCT; see figure 8.1),21-22
participants' apprehension about exercise.
which is fnequently used as a basis for behavior
Although a cancer diagnosis and its conse
change interventions, suggests that we acquire skills
quences may pose barriers to engaging in exercise,
and perform new behaviors by observing others,
they may also serve ■ teachable moment%survi*
as well as by enacting the behaviors ourselves and
vors are interested in taking action to improve their
bring reinforced for our performance. Furthermore,
our behavior is influenced by our expectations
about the behavior formed through both direct and
Take-Home Message observed experiences. These include expectations
심F
斤
Exercise can ameliorate many that we will be able to perform the behavior suc
of the symptoms and side ef cessfully (self-efficacy) and that the consequences of
fects related to cancer and can the behavior (outcome expectations) are predictable
cer treatment. Information on and desirable.
the benefits of exercise for cancer patients Self-efficacy about performing a particular
and survivors can motivate them to begin or behavior has been linked to a range of health
continue an exercise program, particuiarly behaviors, including exercise. It appears to have
those who are retuctant to start a program its most potent influence on exercise adherence at
or are showing signs of discontinuing their times when the exerciser faces new challenges such
exercise program. as beginning a new exercise program^125 and con
tinuing exercise after a structured program ends.25 2*
Figure 8.1 Soaal cognitive theory-based model of exercise adherence.
田，，!•，.
Adapted from Psychology at Spat and Exetcse. Vol. 12. K. Engqust e< al.. 'Design of the steps to heetth study of physcai activity m survivofs at endo-
mctnal cancer: T__ng ■ tocial cograUv，theory modal.* pgr 27*36. copynght 20”. p，rm，，on from
Changes in self-efficacy among participants in exer related first to the initiation of an exercise routine.
cise interventicMis are related to exercise adherence, Whether the persem's expectations are met can affect
but a person、self-efficacy at the start of an exercise long-term behavior change. In particular, studies
program is also relevant and has been shown to have shown that the realization of expected out
predict exercise adherefwe in a range of popnla* comes, such as improved fitness, is related to k)ng-
tions, including cardiac rehabilitation patients,21 > term exerdse adherence/7 and that participants who
overweight sedentary primary care patients,® do not achieve outcomes are more likely to drop
elderly people,w, 12 and women at midlife.11 out than those who do.* * Outcome expectations
Self-efficacy also is related to exercise behavior may also play a role in cancer survivors’ exercise
in cancer survivors. In a survey of breast cancer patterns. Cross-sectional surveys of breast cancer
survivors, self-efficacy about being able to exercise survivors showed that specific positive psycho
and overcome barriers to maintaining exercise over logical and physical outcomes, such as experiencing
time was associated with higher daily energy expen less depression and building muscle strength, as
diture.'4 Self-efficacy at the beginning of an exercise well as general positive expectations scores, were
program for breast cancer survivors predicted how associated with physical activity?4 *3 Higher nega
much exercise (minutes of exercise, pedometer tive expectation scores were associated with less
steps, and percentage of goal met) they did in the physical activity.M
12-week program.35 A study of an exercise and diet Programs that apply SCT to increasing adherence
intervention for breast, prostate, and colon cancer to exercise often use one or more of the four types of
survivors found that self-efficacy at the end of the experiences or information that affect self-efficacy:
program was associated with exercise duration.3* mastery experiences, or successful experiences with
A person's perception of the outcomes that will exercise; modeling, or observing others engage
result from exercise (outcome expectations) are successfully in exercise; verbal persuasion, which
can take the form of social support for exercise as future exercise behavior.47-* Vai lance and col
well as feedback on performance; and physiological leagues'1 tested a physical activity intervention for
states and affect during exercise, such as the experi breast cancer survivors using print material based
ence and interpretation of somatic sensations such on TPB. The group that received the TPB print
as increased heart rate and respiration, muscle material had a greater improvement in attitudes,
soreness, and fatigue.'1-22 Fitness professionals can intentions, and planning (Le., making specific plans
help dients increase their self-efficacy and exercise to start exercising). The effect of the inten ention
program adherence by providing successful experi on physical activity was explained in part by the
ences in a supportive context, providing supportive changes it produced in participants' physical activ
yet realistic feedback on performance, exposing ity intentions and planning.
them to examples of other cancer survivors who Research on TI*B enhances Our understanding
exercise, and helping them distinguish somatic of some of the factors associated with the adoption
sensations that are normal for exercise from those of physical activity and helps identify appropriate
that indicate a problem. In addition, helping clients intervention messaged for particular populations.12
to set positive and realistic expectations about the For example, messages about the benefits of exer
outcomes of exercise should encourage long-term cise may need to be different for cancer sunnvors
adherence. than for other dients, focusing on distraction from
cancer, coping with the stress of cancer, recovery,
Theory of Planned Behavior and Atting back to normal after a cancer diagno
sis. Additionally, the stremg relationship between
Briefly, the theory of planned behavior (TPB) intentions and exercise highlights the importance
states that behavior is a function of the intention of having clients develop specific gaab, ’as well as
to perform a behavior and the person’s perceive^ plans for achieving them.
behavioral control over the behavior (a construct
simihr to self-efficacy). Intention is formed by the
attitudes held toward the behavior, the subjective
Transtheoretic^J/nodel
norm (Le.z the perception of hem* others want the The transtheoretical model (1 IM) incorporates
person to act), and perceived behavioral control. variables from a range of theories. It was originally
Attitudes are formed by beliefs about the outcomes developed to demibe the process of smoking ces
of the behavior weighted by how the person values sation and the psychological variables important
the outcomes. Similarly, norms are formed by the to the process. It has since been applied to other
belief of those in the person's social network about health behaviors, including exercise. Probably
whether she should engage in the behavior, and are the most well-known concept from the TTM is
weighted by the person's motivation to comply with singes of change. According to I IM, people do
social network members.41 not make changes all at once, such as going from
Researchers have applied TPB to explaining being a couch potato to being a committed exer
physical activity in people with breast,42 ** culnnx- ciser overnight. Rather, they go through a scries of
tab45-17 and prostate cancer,*4 as well as in mixed stages in their decision and commitment to change
cancer samples48 and bone marrow transplant their behavior. The stages, which range from pre
patients.** These studies derrumstrate that models of contemplation to maintenance, are described in
exercise behavior for cancer survivors differ some figure 8.2. People in the precontemplation stage
what from those for healthy people,*1 particularly are inactive and not even considering changing.
with regard to the beliefs about outcomes that are Those in the contemplation stage arr beginning to
hypothesized to create attitudes about exercise.公* think about being active and may be researching
Studies vary in the extent to which attitude, subjec or seeking information to weigh the pros and cons
tive norm, or perceived behavioral control predict of exercising. In the preparation stage people often
the intention to exercise, so it is not possible to say make an investment in exercise (e.gM purchasing
which variable makes the most important contri exercise clothes or shoes, making concrete plans to
bution in forming intentions to exercise. However, exercise) and have started being active but are not
intention has been consistently associated with yet doing regular exercise at recommended levels.
Stages of change
Figure 8.2 Transtheoretical model.

Adapted horn Banholomew et, 2001 Infervwfleon Mapp，＞g: Design^g Theory- and EviOence-Based Heath ômo&on Programs Mountain V，，. CA:
MaylMl
The action stage includes people who exercise at

recommended levels, but have done so regularly Translating Theory Into
for less than six months. Those in the maintenance
phase have been exercising regularly for longer
Practice
than mx months. Behavioral theory is useful for helping clients adopt
People adopting an exercise program can move and maintain exercise as part of their lifestyle. The
forward and backward among the stages, depend first step to incorporate theoretical tools in work
ing on their experiences and beliefs about exercise. with clients is to find out about their interests, pref
Different strategies to encourage exercise adherence erences, and lifestyles. Fitness professionals should
are called for at different stages)3 For example, a actively involve clients in the planning process
person in the contemplation stage might benefit to tailor the exercise program to their needs and
more from receiving information about the ben interests, taking into account their exercise goals
efits of exercise than specific information on what and preferences for exercise type group versus
exercises to do. On the other hand, a person in the individual, or a combination), timing, and intensity.
preparation or action stage will benefit from actnn- Fitness professionals should consider their clients’
ties to increase skill and self-efficacy in exercise. It stage of readiness when helping to change exercise
is important to note that movement through the habits (see figure 83 for a form to help evaluate stage
stages is not necessarily linear and may require of readiness), addressing the barriers clients face to
several attempts to move from one stage to another. becoming nwrc active, stressing the benefits of bring
Clients use a variety of behavioral and cognitive more physically active, and helping them become
processes to move across the stages, employing more confident about their ability to be active. For
more cognitive processes (e.g., information gath example, when a client is just starting to think about
ering) at the earlier stages and more behavioral becoming more active, the fitness professional can
strategies (e.g., rewards) at the later stages.18 explore the benefits of exercise and how these match
Therefore, different strategies should be employed with the client’s own values. For instance, exercise
at different stages. may increase her energy level, which will help her
be able to spend more time playing with her grand

children. Additionally, the fitness professional can Take-Home Message
address health issues or other factors that pose bar
Fitness professionals should con
riers to exercise and discuss strategies to overcome
sider the client's stage of readi
thcise barriers. At this stagr raising awareness of the
ness when helping to change
benefits of and barriers to exercise and exploring
exercise habits. When a client or
potential strategies are appropriate. Expressing con
potential client is just starling to think about
fidence in the dienfs ability to become active builds
becoming more active, exploring the benefits
confidence in the client. Pointing out the success of of exercise and discussing how these match
other cancer survivors makes use of modeling and
with the client's values can be helpful. How will
can also promote amfidcnce in the ability to exercise
exercise help _ achieve his lite goals par
and overcome barriers.
ticipate in valued activities? Once a client has
At a later stage of change, when a client is doing
made the commitment to start exercise, build
some activity but wants to increase his activity
ing skills and sett-elficacy is important.
levds or work toward long-term maintenance, addi
tional behavioral theory may be used to promote
achievement of goals. Problem solving about how
to overcome barriers to exercise is appropriate. Dis To increase clients' self-efficacy for exercise, fit
cussions about goal setting sdf.monitoring (i.e., use ness professionals should consider the four sources
of exercise logs), and rewards are also important. of information that affect self-efficacy: mastery
of Change?
accumiiating a! least 30 mmuies

lerate-intensity ptiysical activity
on most (fiw or more) days of the wwk?
Figure 8.3 Identifying your readiness to change.

Adapted, by perm__on. from S_M Blair et al. 2001. Aore Mog every day: 20 we«*3 to I서ong vitality (Champaagn. Human Kmafecs). 9.
experiences, modeling, verbal persuasion and feed Appropriate goal setting can motivate clients to
back. and physiological and affective states. The first exercise (see figure 8.4 for a g(K>l*sctting form). Set
step is developing a plan for exercise that will enable ting and reaching a goal can help clients stay on track
the client to experience success. The fitness profes with their exercise plans. To beeffective, goals should
sional and climt should devekip the exercise plan be selected by the client and should be specific,
together, and the fitness professional should guide measurable, realistic, and attainable in a fairly short
the dient to successful completion of the activity, time period. When discussing the benefits of exer
whether the activity is 10 minutes of walking or a cise, fitness profeSMonab should determine what the
series of stretches or strength exercises. Another client hopes to gain from exercise and help the client
way to build confidence is to identify role models devdop goab based on those interests. Although it
similar in age and ability to the client who have is important to aim high when setting goals, aiming
succeeded with exercise programs. CEents can also too hi안! may result in discouragement if the client
identify people in their own social networks 나4k> doesn't reach the goal in the time anticipated. Fitness
may encourage them to exercise. This may involve professionals should be ready to help their clients
developing a plan for asking a spouse or friend to adjust their goals, if necessary, based on changing
exercise with them or who can provide mor^l or circumstances, and to develop more attainable goals
logistic support. Pointing out recent success in being as steps to reaching longer-temi goals.
active and providing verbal encouragement for Finally, some clients have cancer-related con
recent efforts can increase confidence at this stage. cerns that are outside of the fitness professional’s
Figure 8.4 Ready? Set Goals!

Setting realistic, achievable goals is a key to success.
Are You Doing Any Exercise?

Set a goal to increase the duration or frequency of your activity. Remember to be specific. Think about times
in your day you might be able to fit more activity in.
What is your long-term goal? (Make sure it is specific and realistic.)
What is a realistic short-term goal for you for the next week? (Make sure it
is specific and realistic.)
How are you going to monitor your progress?
How will you reward yourself when you reach your goal?
From ACSM. 2012, ACSM’a gnOe to exercise and cancer survivonfup (Champaign. IL Human Kme*cs).
maintain an exercise program. However, because

a regular exercise program can ameliorate many of
，천夢 Take-Home Message
these issues, cancer patients and survivors should
An appropriatety tailored exer*
be encouraged to avoid inactivity and engage in
cise program and goals can im
regular exercise as much as possible. Ftn* example,
prove self-efficacy. Starting with
several studies have shown that exercise lessens
an accessible exercise program
and achievable individualized goals gives feelings of fatigue, improves physical function
ing and quality of life, and lessens psychological
clients a feeling of success that builds self-
efficacy. Verbal encouragement and normaliz distress. Evidence is also emerging to indicate that
exercise may decrease the risk of developing lymph
ing the physical sensations they may experi
edema, and women who have lymphedema,
ence with exercise may also boost sett-effica
cy. as does seeing others in a similar situation exercise may improve it Evidence is also emerging
to indicate that exercise may improve body image.
accomplish their exercise goals.
Studies in noncancer populations have also shown
a relationship between exercise and improved cog
nitive functioning and better sleep quality. These
area of expertise. Fitness professionals should be benefits should be emphasized in working with this
familiar with support groups and other services in population, particularly with clients experiencing
the community for people with cancer, so they can these difficulties. Using theory-based approaches
refer clients having undue difficulties such asosy- can optimize the effectiveness of exercise pro
chological distress, severe fatigue, or lymphedema. gramming for cancer patients and survivors; these
The local chapter of the American Cancer Society approaches include tailoring messages to clients,
can be a good source of this type of infcwnvition. Its readiness to change, increasing self-efficacy, and
website lists services such as support groups and helping clients set goals and identify rewards.
health education in a person’s local area (www.
cancer.org/asp/search/crd_global.asp). References
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2- Arndt V, C, Ziegler H, Brvnner H. Apopu-
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심■ Fitness professionals should re on qiMiUty of life in women with breast cancrr 1 year
cognize that some of the con afttr diagnosis. Cancer. 2006; 107:2496-2503.
cerns and problems their clients 3. Meeskc K, Smith AW, Alfano CM, McGregor BA,
are experiencing may be beyond McTicman A, Baumgartner KB, Malone KE, R«?vc
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TM. UndcrsUnding exercise motivation in coloivcUl 27-35.
CHAPTER 9
Safety, Injury
Prevention,
and Emergency
Procedures
Anna L. Schwartz, PhD, FNC FAAN 乂
following:
• Knowledge of and ability to recognize and respond to cancer-specific safety issues, such
as susceptibility Io infection, musculoskeletal and orthopedic changes, unilateral edema,
fatigue, lymphedema, neurological changes, osteoporosis, cognitive decline associated with
treatment.
• Knowledge of and ability to respond to cancer specific emergencies, including: sudden loss of
limb function, fever in immune-incompetent patient, and mental status changes.
• Knowledge of and ability to respond to the signs and symptoms of new-onset and major life
threatening complications of cancer, such as superior vena cava syndrome (SVCS), sepsis or
infection, and spinal cord compression.
• Knowledge of and ability to write up incident documentation related to cancer specific adverse
events.
Safety, injury prevention, and emergency proce hematopoiesis, myelosuppression, and impaired
dures are critically important when working with cell function increases the risk of infection.
cancer survivors. All the safety and injury preven Fever is the cardinal symptom of infection in
tion strategies that are used with healthy exercisers cancer survivors with low white blood cell counts.
must be observed, but additional a>nsideratians Fever is defined as three consecutive oral tempera
and precautions must be heeded with this popular tures of >38 °C or 100.4 °F in a 23-hour period, or
tion. This chapter discusses cancer-specific safety one temperature >38.5 °C or 101.3 °F. However,
amsideratiom, emergency procedures, and incident fever may be suppressed in cancer survivors who
report documentation related to functional changes are actively recei\Tng treatment and have extremely
of the immune, neurologicat and musculoskeletal low white blood cell counts; these people may not
systems. have an adequate immune function to mount an
immune response.
Prevention of infection is critical, especially when
Cancer-Specific Safety a cancer survivor is actively receiving treatment.
Strategies to reduce risks for infection include
Considerations good hand washing and avoiding sick people and
crowds. If a cancer survivor develops an infection,
Fitness professionals should be familiar with and
medical treatment focuses on antibiotic therapy
aware of several important cancer-specific safety
until the infection resolves. Untreated infections
ainsideratkms. These include changes in immune,
can develop into sepsis, or septic shock―a seri
neurological, and musculoskeletal functions. Also,
ous systemic infection. Septic shock can cause
emergency procedures should be in place to ensure
multisystem failure including cardiovascular func
quick responses and the clear and accurate docu
tion, microvascular perfusion, and oxygenation
mentation of incidents.
of tissues. The mortality rate from septic shock is
between 30 and 50%/
Immune Changes
The cause of infection in cancer patients is multifac-
torial and can be from the or treatment-
related? Infections that arise from the disease
Take-Home Message
Fitness professionals should re
occur when the bone marrow becomes infiltrated
mind clients Io wash their hands
with cancer cells from cancers such as leukemia,
and faces after exercise. This is
multiple myeloma, and lymphoma. Infection in
an easy way to reduce the risk
an i mm iine-<oiTiprofnised cancer survivor can be
for infection.
a medical emergency; the immune-compromised
cancer survivor with a fever can quickly develop
sepsis if the infection is left untreated.
Tredtment*rehted infection can be caused byi A fitness professional who encounters a cancer
variety of therapies including myelosuppreasive survivor with fever should focus on helping the
chemotherapy, which includes drugs that cause a person seek medical care before the fever escahtes
decrease in the production of cell lines (fed blood to a serious infection or sepsis. It is vital that the
cells, white blood cells, and platelets), radiation professional recognize the signs of infection and
therapy, and corticosteroids.1，Chemotherapy can period of risk and refer the cancer survivor to her
decrease the number and function of white blood health care team immediately. The survivor should
cells, red blood cells, and platelets. Radiation to not exercise at this time. Documentation should
sites of active bone marrow production, such as include information related to the presentation
the sternum, pelvis, and long bones, may reduce of the fever or infection, how long the person has
hematopoiesis (the formation and development reported the symptoms, and where the person was
of blood celb). Corticosteroids suppress immune referred for treatment. Before the client returns to
function by reducing the number of white blood exercise, the fitness professional should confer with
cells and their function. The combination of reduced the survivor and her health care team to leam about
Safety, Injury Preventkm, and Emergency Procedures 155
and causes people to have trouble using and even
Take-Home Message undcnstanding words and sentences. Symptoms
겼 Chemotherapy can increase cli

ents' risk for infection. Clients re
ceiving chemotherapy should be
asked whether they are having
range from almost imperceptible to acute, and the
severity can range from insignificant to severely
disabling and life threatening. Brain tumors and
metastasis to the central nervous system and brain
any fevers or chills. They should talk with their can cause neurological changes related to cancer.
medical team if they are feeling sick in the Treatment-related neurological changes include
peripheral neuropathy (numbness in the fingers,
days following chemotherapy administration.
toes, or both) and cerebellar dysfunction, and are
cocnmordy reh ted to treatment with agents such as
paclitaxel, cisplatin, and high-dose cytosine arabi
any physical limitations that need to be accommo noside. Central nervous system infection and sepsis
dated. Obtaining medical clearance for the client can also cause neurological disturbances.
to resume exercise may be prudent for the fitness Spinal cord compression is a medical emergency.
professional. Prompt medical intervention can reduce the risk of
A clean facility can go a long way in ensuring permanent neurological disability including sen
that clients have a healthy exercise experience. sory and motor deficits and paralysis,9 Back pain,
Documenting a cleaning regime is a good way to motor weakness, and decreased sensation are early
provide this dean environment (see figure 9.1). symptoms of spinal cord compression that usually
occur over months or within days or hours, depend
ing on how aggressively the tumor or tumon are
Neurological Changes growing. Symptoms vary, but cancer survivors may
Neurological symptoms can be profoundly dis complain of heaviness and stiffness in their arms or
abling, both physically and psychologically, and legs, or tingling or numbne* in their fingers and
may be a complication of cancer or its titatment. toes. Late symptoms include motor loss, sensory
Symptoms may occur at any point alon^the disease less, loss of proprioception, and autonomic dysfunc
trajectory and range from subtle anxiety to expres tion. Propriocepbcxi the unconscious awareness
sive aphasia. Aphasia results from brain damage of movement and spatial orientation.
Figure 9.1 Twice-Daily Facility Cleaning Checklist

Task Date Initial sAime Date Initials/time
Soap dispensers filled
Soap dispensers work
Antibacterial dispensers filled
Antibacterial spray bottles filled
Paper towel dispensers filled
Clean towels available
AN counters cleaned
Exercise equipment cleaned
Showers cleaned and disinfected
Toilets cleaned and disinfected
Trash cans emptied
Soiled linen emptied
From ACSM，2012, ACSM s guKie to exerose and cancer survYvorah<> (Champaign. IL Honan Kmeecs).
Personal trainers need to be aware of cancer should be advised to use stationary equipment that
survivors at risk and quickly recognize neurological he cannot drop or sustain an injury from. Peripheral
changes that may occur. Cognitive declines (e.g., neuropathy in the toes and feet may affect balance
changes in memory, attention, or decision making) and may require program modifications to reduce
or changes in mental status may herald neurological the risk of falls. Fitnrss professional may want to con-
changes that need prompt attention. Cbents who skier working on a dient's balance and coordination.
appear disoriented, restless, drowsy, or unsteady, or The superior vena cava (SVC) can easily be com
who have marked weakness in their legs or a change pressed by mediastinal (chest) tumors.7" Obstruc
in their gait, need to promptly seek medical care. tion of the superior vena cava causes pleural effu
Unfortunately, treatment for spinal cord compressions and facial, arm, and tracheal edema. When
sion can only limit or ameliorate the symptoms to superior vena cava syndrome (SVCS) becomes
prevent further disability. severe, brain edema and dampened cardiac tilling
Peripheral neuropathy is caused by inflamma may impair consciousness and neurological func-
tion and injury to the peripheral nerve fibers and ticn. Symptoms depend on the extent and rapidity
occurs most commonly in tfie fingers and toes, but of the SVC compression. Only a small percentage of
may also extend centrally.* Peripheral neuropathy patients with rapid-onset SVCS are at risk for life
is a common side effect of many chemotherapeu threatening complications. Although SVCS can be
tic agents and can significantly threaten personal a medical emergency, it most commonly presents
independence and quality of li^. This side effect is with the gradual cnsef of symptoms that need to be
often described as a feeling of *pins and needles* evaluated and treated promptly? 10
in the hands or feet. It can be painful and can make
simple, everyday tasks, such as picking up a coin or
Musculoskeletal Changes
buttoning a shirt or blouse, difficult if not impos
sible. Severe peripheral neuropathy can cause loss Musculoskeletal changes can range from weakness
of fine motor control, and foot and wrist drop. and atrophy to actual loss of limb or limb func
The risk of injury from peripheral neuropathy is tion. Musculoskeletal symptoms vary according to
related to decreased sensitivity to temperature, gait whether the change is a result of surgery, disuse, or
distuibance, and reduced pnipriocepticxv The fitntfs disease. Limb amputation from a caiKer such as a
professional needs to be aware of cancer survivors sarcoma causes sudden, life-changing alterations in
with peripheral neuropathy and make accommcxia- mobility and strength. Surgery that disrupts muscle
tiims to the exercises they perform and the equipment fibers, lymph nodes, and nerves can significantly
they use. A survivor with penpheral neuropathy in alter range of motion and muscle function. Muscle
his hands mav not be able to hold dumbbells and weakness and atrophy from disuse may be the most
enmnwn cause of musculoskeletal change in cancer
survivors and can render a fully functioning person
weak and debilitated. Bone density and structure
、외 지 Take-Home Message can be negatively affected by metastatic cancer,
When a client is actively receiv bone cancer, or chemotherapy. Metastatic bone
ing chemotherapy with drugs cancer can change the architecture of the affected
such as paclitaxel, the fitness bones increasing the risk for fracture. Certain che
professional should be sure to motherapy agents and corticosteroids cause bone
ask whether she is experiencing any numb wasting and also increase a cancer survivor's risk
ness in her fingers or toes. The longer the for osteoporosis and fracture. Many of the drugs
client is on chemotherapy with agents that used to treat or control cancer contribute to bone
cause peripheral neuropathy, the worse the loss, which may be further accelerated by inactivity
condition is apt to get. The fitness profes* during and following treatment.
sional should plan an exercise program that Muscle atrophy from disuse can be slowly
reduces the risk of dropping weights and corrected with exercise. However, exercise may
works on balance. need to be modified to accommodate for loss of
limb function, limited range of motion, peripheral
Safety, Injury Preventkm, and Emergency Procedures 157
neuropathy, and impaired balance. Core strength Preventing lymphedema is difficult. Exercise,
exercises should be used to help survivors with both aerobic and resistance, is safe.11 ° Howrver,
balance problems (fitness professionals should give resistance exercise must be done methodically.
examples and site the muscles to be used). The exerciser should start a program without any
additional mistancr and xknviy pr^gresn to adding
resistance with weights. A recent study of women
with lymphedema demonstrated that resistance
—Take-Home Message exercise reduced the incidence and severity of
Cancer survivors may be debili
lymphedema.11 Many patients with lymphedema
tated with poor muscle strength
wear compression sleeves to control the swelling,
and cardiopulmonary status.
and the National Lymphedema Network recom
Fitness professionals need to
mends that cancer survivors with lymphedema
assess what type and how much physical
wear compression sleeves when they exercise.
activrty clients have been doing before they
Unibteral edema may be a sign of circulatory
begin an exercise program. Many clients will
obstraction and should be considered a risk for
say that they used to run and lift weights,
exercise. Unless the cancer survivor can attribute
but with further questioning, fitness profes
the one-sided swelling to a specific recent injury,
sionals may discover that was 30 years ago!
he should not be permitted to exercise. The cause
Exercise programs must be individualized to
of unilateral edema could be infevtion, a tumor
ckents* abilities and where they are now, not
compressing surrounding structures, or new-onset
where they were 30 years ago.
lymphedema. Survivors presenting with unilateral
edema should be referred to their medical team for
ex'aluation and treatment.
Patients with known bone metastasis or osteo
porosis sh(mld be monitored dosehr. Weightlifting
should be limited to weights they can manage using
correct form throughout the full range of motion. Take-Home Message
Ideally, this would be determined through 1- Clients at risk for lymphedema
repetition maximum testing, but rating of perceived should be asked before ev
exertion could also be used to determine appropriate ery exercise session whether
weights. Ba lance and core strengthening are particu they leel any new or worsening
larly important for people with these conditions to swelling in their fingers, arm. or chest. The
decrease their risk of falls and improve their balance. fitness professional should adjust the exer
l.\*mphvdema is perhaps the most common cise session if the client reports new-onset
and disabling side effect of surgpry. Lymphedema or worsening of lymphedema and recom
causes swelling in the affected extremity, either from mend that she talk with her medical team.
an abnormality in the production of lymph fluid or, The professional should make a note of this
more commonly, an obstruction of the circulating in the client's exercise chart and include de
lymph fluid. Lymphedema can occur immediately tails about when the lymphedema started,
following surgery or be triggered months or years what the client is doing about it, and how the
after surgery as a result of radiation therapy or an exercise program was modified.
infection. Common surgical sites related to lymph
edema are dissection of the axillary nodes in the
armpit and the inguinal nodes in the groin (less
common). Lymphedema causes pain and shiny,
swollen skin that feels full and tight. It can cause
Emergency Procedures
swelling in the fingers, hand, ann, or leg. Swelling A facility should have written contingency plans
may be intermittent, disappear entirely, or persist. in place to manage emergencies. The astute fitness
Lymphedema impairs circulation and increases the professional can oftm prevent a serious emergency
risk of infection in the affected extremity. by carefully observing subtle changes in a cancer
survivor and actively listening to the client. Most in a clients health status, details of safety and emer
people cither don't feel quite right or have unusual gency procedures, and n.wrds of referrals to medical
sensations or feelings prior to a significant event. care. Changes in health status should be documented
Close attention to the onset of new symptoms and including the date of onset, changes in medications,
attenuation of the exercise program may be suf physical condition, and physical ability.
ficient to thwart an emergency situation. Following an emergency, documentation should
A fitness professional who recommends that a include careful notation of the time and date of the
cancer survivor see a physician is responAibie for incident, specifics of what happened to the client,
documenting this and following up with the sur and what was done to render aid. Documentation of
vivor, the medical team, or both. In an emergency, where the client was sent for medical care and how
obtaining medical care promptly is critical. An the client was transported there should be rtxorded.
emergency plan can be as simple as calling 911 and All notes should be fully written out, in clear and
staying with the client. The fitness professional is not concise statements. Before a cancer survivor returns
responsible for determining the cause of the illness, to exercise, the fitness prpfessional should ask for a
but is responsible for acting quickly and within the medical release, or sign a release of responsibility if
scope of practice, and for thoroughly documenting no medical consent for exercise is provided.
the event after the cancer survivor has been attended
to by the appropriate medical personnel.
Take-Home Message
Documentati 매
심Clear, accurate documentation
after every exercise session is
Complete and accurate documentation is one of important for planning the next
the most important skills for a fitness professional exercise session and showing
working with cancer survivors to develop. Accurate clients how they are progressing. Documen
written documentation is an integral aspect of risk tation is also important for risk management
management and is critical when a client has new after an emergency.
onset of symptoms, has a serious untovrard event
or emergency, or is returning to exercise after an ill
ness. Fitness professionals can be held accountable
for what they do or do not document about a client,
so they need to think carefully about the sequence
Summary
of events that occurred and document exactly what Cancer-specific safety issues include susceptibil
they did, and, if posable, cite any witnesses to the ity to infection, musculoskeletal and orthopedic
event changes, unilateral edema, fatigue, lymphedema,
All documentation should be written in ink neurological changes, osteoporosis, and cognitive
and Mgnt*d M the end of the note. If written on a decline associated with trvatment. Cancer-specific
computer, the document should be electronically emergencies may be avoided by knowing the
signed or printed out and signed, and then added signs and symptoms of newr-onset and major life-
to the survivor's exercise record. (See figure 9.2 for a threatening complications of cancer. Any incident
sample documenta由on form.) Fitness professionals related to a cancer-specific adverse event should be
need to maintain clear, accurate records of changes well documented.
Figure 9.2 Incident Report Form
Date of incident Time of incident:
Client's primary complaint/problem:
Details of Event
What was the client doing?
When did it happen?
How did it happen?
Who else was present? _ ____________________________
Were there any witnesses present?
What actions did you take?
What medicaJ attentkxi was sought?
Was client transported to:
Doctor? Ybs No
Emergency department? Yes No
How was client transported? Ambulance Private car J
Required before client can return to exercise:

Medical release to exercise
Review of any new exercise limitations with health care team
Discussion and documentation o< client's concerns and fears about returning to exercise
Sign:
Date:
Fratn ACSM, 2012. ACSM'aao •xerc編• 離td cancf turvtvonfup (Champaign. IL Human Kmattca)
159
References 7. Nunnelee J. Superior vena cava svudrome. / Vase

Nun. 2007; 25(1》: 2-5.
1. Rieger C, Herzog C Eibel R, Fiq(l M, Osêrmann H.
Pulmonary MRI—Anew approach for the evaluation 8. Wan JF, Bezjak A. Superior vena cava syndrome.
of febrile neutropenic patients with malignancies. Emerg Med Clin North Am. 2009; 27(2)： 243-255.
Sttpffort Gwr CMCtr. 2008; 16： 6,599-606 i、: i::，• 9. Colen FN.Onailopc emernencwj*: Superior vena cava
lication date July 1,2008. syndrome, tumor lysis syndrome, and spinal cord
2. Nationai Cancer Institute. Suneillance. Epidemiol compression. / Emerg Nurs. 2008; 34(6)： 535-7. Epub:
ogy, and End Rvtiults inttiative (SEER), http: / /seer. September 5, 2008.
cancer.gov. Accessed July 21,2011. 10. Walji N, Chan AK, Peake DR. Common acute
3. Williams DM, Braun LA, Cooper LM, et al. Hospi- oncological emergencies： Diagnosis, investigation
Ulized cancrr patients with seven? sepsis： Analysis and marugvmvnt. Pixl^rad Med /. 2008; 4(9^1)： 418-
oi incidence, mortality and associated co&ts of care. 427.
Critical Can. 2008,8: R291-R298.
11. Schmitz KH, Troxel AB, Che\rillc A. et al. Physical
4. Regazzoni CJ, Irraz^bal C, Luna CM, Podero«o activity and lymphedema ftfu* FM. trial): Aw«s»ing
JJ.Cancer patients with septic shock： Mortality pre the safety of pnigresistve strength training in breast
dictors and neutopenia. Support Care Cancer. 2004; 12: cancer surx ivor& Contcmp Clin Trials. 2009; 30(3): 233-
833-839. 245. Epub： |anuar)' 8, 2009.
5. Loblaw DA, Perry J, Chambers A, Laperriere NJ. 12. Sa gen A, KAresen I^Risbef^ MA. Physical activity tor
Systematic review of the diagnosis and management the affected limb and arm lymphedcnu after breast
o( maligrunt extradural »pinal cord ciimpmskm: The cancer Mirgcrjt A prubpcctive, randomized amtrolled
Cancer Can* Ontario Practice Guidelines Initiative's trial wtih years follow-up. Acta Oncol. 2009；
NeuroOncology Disease Site Group. / Clin Oncol. 23:1 山
2005: 9(20)： 2D2B-2037
13. Harvicr V. Breast canccr-rvlatcd lymphoedema:
6. Quasthoff S, Hartung PH. Chemotherapy-induced Ri>k iaitors and treatment. Br / Nun. 2009; 18(3):
peripheral neuropathy. / Neurol. 20Q2; 249( 1 )： 1432-1499. T66-172.
CHAPTER 10
Program
Administration
Carole M. Schneider; PhD
following:
• Knowledge of rote in administration and program management wrthin a cancer center, cancer
treatment facility, and outpatient setting.
• Knowledge of the types of exercise programs available in the community and which of these
programs cater specifically to the needs of cancer survivors.
• Knowledge of and ability to implement effective, professional business practices and ethical
promotion of personal training services to the cancer care community (e.g., physicians, nurses,
social workers, physical therapists, survivors and their families).
• Knowledge of the Health Insurance Portability and Accountability Act (HIFÂ) and ability to
implement systems to ensure confidentiality of cancer-related protected health information of
participants.
• Knowledge and ability to obtain referral from physician and communicate with physician about
adverse events, abilities and limitabons of survivor, and outcomes of testing and training.
• Ability to recommend appropriate websrtes and refer to other health professionals.
• Knowledge of reimbursement programs as eligible/available.
• Knowledge and ability to recognize the limits in the scope of practice for exercise professionals
in working with cancer survivors with complex medical issues.
• Knowledge of how to communicate effectively with the major medical specialties with whom
cancer survivors may interact, including surgery, medical oncology, radiology, dietitians, and
psychologists/psychiatrists.
161
Cancer exercise rehabilitation program develop physicians, case managers, oncology and rehabili
ment and administration requires that fitness pro tation nurses, social workers, psychologists, occu
fessionals have the knowledge and skills to work pational therapists, dietitians, speech therapists,
with the medical community as well as the cancer vocational counselors, and physical therapists.
survivor who may have multiple trvatmmt-rulated Physical therapists had the role of optimizing physi
complications. The goal of developing a cancer exer cal functioning. The difficulty with physical therapy
cise rehabilitation program is to deliver quality care is the limited time therapists have to evaluate and
with appropriate exercise assessment, prescription, treat cancer survivors. As a result Certified Cancer
and intervention while also providing education Exercise Trainers were needed in the field of exer
and safe programs by certified and qualified per cise physiology and fitness.
sonnel. This chapter presents information on the
administration and management of cancer exercise
rehabilitation programs with special emphasis on
operational procedures, the roles and responsi
Designing a Cancer
bilities of the rehabilitation team, reimbursement Rehabilitation Program
issues, and outcome evaluation.
Cancer rxerrisf rehabilitation program develop
ment includes four steps: a needs assessment,
program development, program implementation,
서앞 Take-Home Message and program evaluation.1 The needs assessment
Because cancer survivors do involves surveying the needs of the cancer sur
not represent an "apparently vivor population. This information, along with
healthy" population, cancer ex information about community needs (e.g.. Is the
ercise rehabilitation should be local YMCA interested in offering exercise classes
conducted by trained and certified cancer ex for cancer survivors? Are them any exercise classes
ercise specialists, or trainers These profes in the cancer survivor's cotnmunih*?), can assist in
sionals need to be familiar with many types the detennination of pro容ramming and services.4
of cancer, the types of cancer treatments, The needs of survhcwK and their community can
and the side effects of the cancer and its be determined using instruments and strategies
treatments. Individualizing the program for such as market surveys, participant surveys, focus
each cancer survrvor ensures the delivery of groups, current community program evaluations,
quality care. and local organization databases (e.g., American
Cancer Society).
Foiknving the needs assessment and the deter*
The rehabilitation of cancer survivors and the nunatian of the community's needs, the next step is
amelioration of cancer treatment-related side developing the program. Developing the program
effects(iriginak*d with the National Cancer Act of begins with creating a mission statement and then
1971. The legislative objective directed funds to the developing program goals that support that state
development erf training programs and research. In ment. Objectives, developed next, should support
the same year, the National Cancer Institute spon both the mission statement and the goals. Objec
sored the National Cancer Rehabilitation Planning tives form the basis for program decisions and help
Conference, which identified four objectives for the determine program success.4 See the sidebar Mis
rehabilitation of cancer survivors: (1) psychosocial sion Statement, Goals, and Objectives for a Cancer
support, (2) optimization of physical functioning, Rehabilitation Program.
(3) vocational counseling and (4) optimization of Creating an organizational structure of program
social functioning? staff is the next »tep in program development.
Cancer rehabilitation requires a multidisdplinary" Figure 10.1 shows an example of an organizational
approach because of the many complications and structure. The board of director's role is leader
toxicities of cancer and cancer treatments? To meet ship rather than management. The board provides
the four objectives, the cancer care team included oversight and direction to senior administration on
、
Program Administration 163
Mission Statement, Goals, and Objectives

for a Cancer Rehabilitation Program
Mission Statement
Advance the quality of life of cancer survivors during and following cancer treatment through
prescriptive exercise rehabilitation.
Goals
• To provide scientifically based individualized prescriptive exercise programs tor cancer survivors.
• To increase the number of clients by 15% each quarter.
• To educate cancer survivors concerning the continuum of cancer care.
Objectives
• To gather researcti findings on exercise and cancer rehabilitation and design the exercise pro
gram based on these research findings.
• To prepare a brochure that defines ttie services of the cancer rehabilitation program.
• To provide cancer survivors with educational materials that enhance their understanding of the
cancer care process.
issues such as financial oversight and governance. physical therapists) to ensure quality patient care.
The director develops and implements policy and The business manager may specialize in a specific
strategy, provides strategic leadership, works with area of the organizational operations. For example,
the community, and manages staff and resources. a business manager may specialize in purchasing,
The medical director oversees clinical care and personneL or administrative services. In other
works with the interdisciplinary team (nurses. cases, a business manager may be held accountable
Figure 10.1 Organizational structure.
for the accuracy of the financial reporting for the

organization. The clinical coordinator is responsible
타 Take-Home Message
for the day-tewlay operations of the clinic such as
scheduling client appointments, managing the clini
＞심, A successful cancer rehabilita-
, tion program must have an eval
cal staff (fitneiK professionals and dietitians), and
uation process. Every program
developing the assessment and procedural manual
has to be justified to some type
for the clinic. The fitness professionals, dietitians,
of higher administration. Program managers
nurses, and physical therapists are responsible for
have to be able to show psychological and
the implementation of the program interventions/
physiological progress in clients to merit con
Program planning includes choosing the com
tinued funding.
ponents of the cancer rehabilitation program. The
Rocky Mountain Cancer Rehabilitation Institute has
seven components: screening; physical examina*
tian; physiological and psychological assessment, staff and participants by asking survey questions
reassessment, and prescription; dietary evaluation; such as the following: What are we doing? When?
individualized prescriptive exercise interventions; Where? Hw much? Are we delivering the program
clinical and basic research; and advanced educa as planned? If not why has it varied? Are we on
tional and professional development to promote track with time and resources? What is not working
high standards in cancer rehabilitation.1' However, very well and why? Are we reaching the target audi
cancer rehabilitation program components will vary ence? Questions should address the appropriateness
based on the results of the needs assessment and the of the focility, program delivery, staff performance,
program content. the schedule of activities, and the appropriateness

Once program preparation is complete, budget of the screening process.*
ing,, program pricing, and marketing plans should Outcome evaluation looks at the program results.
be established. Financial expenses may inchidc Questions to ask may include the following: What
employee salaries and benefits, equipment and did we accomplish? Did we achieve our outcomes?
materials, and marketing. Careful consideration Why or why not? What can we learn from the par
must be given to the number of participants needed ticipants who dropped (nit o( the program? What
to at least break-even in regards to revenue and could we do differently next time to achieve better
financial status. The financial statement should outcomes? Were there external influences that
show the movement and availability of funds could have enhanced vr hindered the achievement
through and to the program over a given period of of expected outcomes? These questions address
time. All financial revenue、and expenses should be revenue versus expenditures, the number of new
reviewed on a regular basis. Program implementa participants, and participant performance ascer
tion is based on the decisions made in the program tained through pre- and postexerdse assessments.
planning phaw regarding marketing strategies, Evaluation can be performed at any time
staffing, and budget. throughout the program.* Table 10.1 is a sample
Program evaluation should begin during pro template of an outcome program evaluation plan.
gram implementation. Evaluation is essential to Management of the program and personnel is
ascertain the effectiveness of the program and necessary to provide physical, psychological, social,
determine whether program and financial objec- and professional conditions within the facility that
tives are being met. Program evaluation is a sys will optimize the services offered. For cancer reha
tematic method for collecting, analyzing and using bilitation, this means responding to every aspect of
information to answer basic questions about the the operation to ensure that exercise interventions
program. are making a positive difference in the quality of
The types of program evaluation are process life of cancer survivors. Successful management
evaluation and outcome evaluation. Process valu is based on leadership and vision. The director, or
ation assesses the effectiveness of the components manager, should be able to empower others to act
of the program so that adjustments can be made, if as needed to create an environment of trust, confi
necessary, to stay on track. Data are gathered from dence, and pride.
TABLE 10.1 Template for Program Outcome Evaluation

Steps to
Target achieve the Analysis and Person
Program goal outcome outcome Results action plan responsible
Provide a 85% Participants Pre- and post Analyze Clinical
scientifically improvement are offered a intervention program 乂 coordinator
based, in physical comprehensive, fitness intervention
individualized performance individualized assessments lo see where
prescriptive three-month that show that program can be
exercise exercise participants strengthened
intervention intervention improved 75%
for cancer on oxygen
survivors consumption
and time on
treadmill
Total quality management is a good theory to Regardless of the setting, the target population
follow for cancer rehabilitation programs.7 The determines the needs of the facility. In cancer
scientific model that most closely fits the theory rehabilitation, the needs of the target population
of quality management is the model of Grantham usually are based on health goals ar fitness goals.
and colleagues*: the Theory of Quality Manage Clinical settings usually address health goals such
ment. This model focuses on providing the best as improving health and preventing the onset of
service in the most efficient way, which tramddtr、 recurrence while improving physical functioning.
into high quality at low cost If the management Programs address education, behavior modifica
process is effective, every aspect of clinical service tion, and exercise programming that emphasizes
will be effective. initial, improvement, and maintenance phases.
The program begins with a gentle introduction
to physical activity* and emphasizes consistent
Cancer Rehabilitation participation and proper technique. The improve

ment phase provides gradual nonlinear progres
Programs and Settings sion based on the health status of the cancer
survivor. Some days the person will not be able
A few factors to ccxisider when developing a cancer
rehabilitation program are the convenience of the
facility location, scheduling that does not interfere
with community programs, liability waivers and Take-Home Message
informed consent required in the area, the number The type of exercise program
of program participants in relation to the number will depend on where the client
of staff members, and the type of staff (e.g" cancer is in the cancer continuum. If the
exercise specialists, physical therapists). client is in the treatment phase.
Cancer rehabilitation programs take place in a then the exercise workout will be low io moder
variety of settings. However, the majority of suc ate in intensity with moderate-intensity work
cessful programs are clinical, occurring tn hospital outs on good days and low-inlensity workouts
or physical therapy settings because of reimburse on bad days. Fitness professionals determine
ment issues and the access to cancer survivors. A the good and bad days by asking clients how
limited number of cancer rehabilitation programs they feel that day. They should also take note
are located in community facilities such as YMCAs. of when the client had treatment; until more
Even fewer comprehensive cancer rehabilitation research is completed that may suggest oth
programs take place in commercial settings. These erwise. clients should not exercise the day of
usually have programs for survivors following their or the day following treatment.
cancer treatments.
to exercise as hard as on other days, espedally if

she is going through treatment. Therefore, progn，—
Take-Home Message
sion will be gradual and nonlinear. The mainte 심Assessments should include
nance phase of the program encourages lifestyle
possible toxicities clients may
changes in exercise habits and adherence to those
have experienced with cancer
changes.
treatment (e.g., cardiovascu
A target population that consists of people who
lar assessment because of cardiovascular
want to become more fit would receive program
toxicities with chemotherapy). Because no
ming based on the goal of getting stronger or losing
direct correlation exists between symptoms
weight. The programming would address looking
and toxicities. a variety of assessments
better or feeling better, and the exercise prescription
should be done that include al systems of
would concentrate more on the improvement phase the body.
of exercise programming. This type of program
ming would be for cancer survivors who are at least
six months out from treatment14
Individualized or personalized exercise prescrip
Program Description tions should be based on the clienfs assessment

results, and exercise interventions or programs
and Operati 에 s offered at the facility should be based on the exer

cise prescription. For example, if an intervention
Although other cancer rehabiMtation programs or program is to be offered for cancer survivors
exist, this section provides an overview of a pro who are new to exeacise, and their prescription
gram that has been successful in meeting specific recommends supervised exercise at a moderate
objectives such as improved psychological and intensity, then the intervention or program should
physiological performance and high levels of be just that. Following the program planned length
participation. The cancer survivor chart should be of your exercise intervention, reassessments identi
developed first so as to assist in the collection of cal to the initial assessments should be completed
important information. Figure 10그 displays what to detennine whether the objective of improving
should be in the client’s chart. fitness has been met表 *
Every climt should have a health screening prior A well-designed operational plan should be
to participation in the program. Screening forms can established for the facility. Basic procedures such
be sent to clients so they* have 由me to complete them as opening and dming procedures, quality control
before coming to the facility. The health scream within the facility, and emergency procedures
ing should include a cancer history, medical and need to be established and carefully implemented.
family history, risk factor analysis, lifestyle valu Because clients will expect consistency in the open
ation, fatigue scale analysis, depression inventory, ing and closing of the facility, an empk)yee should
quality of life index, and dietary record. A physical be assigned this task and be given a checklist that
examination is not always necessary, but if a physi outlines the opening procedures and closing proce
cian is available to do one, the fitness professional dures. The opening checklist may include checking
should present the client to the physician (figure the cleanliness of equipment (especially important
10.3). A comprehensive fitness and nutritional for cancer survivors who are highly susceptible to
assessment should be conducted because cancer infections), checking the availability of perishable
treatment-related toxidties affect the entire body. supplies used for the program, and ensuring that
Assessments should include cardiorespiratory safety equipment is functional. The dosing checklist
endurance, pulmonary function, pulse oximetry, should include securing all doors and windows and
muscular strength and endurance, balance, body turning on alarms. The sidebar Topics for Operat
composition and circumference measurements, ing Procedures for Cancer Rehabilitation Facilities
flexibility and range of motion, and dietary analysis lists topics that need to be a part of the operational
and counseling. plan of the facility.
Figure 10.2 Chart Contents: Initial Assessment
Name:
Document Date completed Initials
Right side
Charting sheet
Exercise prescription
Data collection sheet (assessment)
Biodex printout
Pulmonary printout
Piper Fatigue Scale
Beck Scale
Quality of life index
Informed consent
Car必ovasculaf disease risk factors
Lifestyle evaluation
Dietary analysis
Correspondence 정^^—
Left side
■斤'
Problem list
Cancer history
Medical history
Physical exam
Insurance information
From ACSM. 2012. ACSM、gt眞1_ to and cancer «urvM>ra서p (Champ«gn. I: Human Kimlica) RaprvMed from C M. Schn_d，r. CA Dannehy
•nd SH Carler, 2003. btict— and cancer recovery (Crwnp«ign. 匕 Human Km_ca》. 1ST U_d by p_rmi_on of fte Rocky Cancer
Mitabon institute
1S7
Figure 10.3 Presenting the Cancer Survivor to the Physician
Name: Age辨匕
Referral source: Primary care physician: _________________________
Last visit to cancer rehabilitation center was years ago
Diagnosis
Type of cancer (location): ______________________________
Stage of cancer (if known): _______________________________
History of Present Illness (HPI)

Date/s of diaonosis: 乂
Surgeries (type and date): _ ________
Chemotherapy:
Radiation: ___________________________________ ________________
Cancer History
Since last visit to cancer rehabilitation center, cancer history (circle one): Has changed Has not changed
Changes include: —________________________________ __________________________
Recurrence: ___________________________________
New treatment:
Completed treatment 그^，

Problem List
Other significant medical illnesses: ___________________________________________
Current problems:
Medical History
Since last visit to cancer rehabilitation center, medical history (circle one): Has changed Has not changed
Changes i nclude:
Medications (drde one): Has changed Has not changed
Medications and reasons for particular medications:
Changes include (new medication, discontinued medication, and change in prescribed amount):
Family History
Other cancers:
Serious diseases:
Allergies
Medications:
168 Latex, tape, and so on:
Figure 10.3 Presenting the Cancer Survivor to the Physician (continued)
Current level of activity

Type of exercise:
Duration:
Frequency:
Length of time client has participated in this type of exercise:
Lab
Recent significant results, if known:
Goals
Short and long term during the exercise program: ________________________
Accessibility to exercise equipment, facilities, and transoortatio며 드 -
From ACSM. 2012. ACSM'a gutdt k> exercise and canoar aurvivonftp (Champ^gn. IL Human Knetocs》. RapmtBd. by permission, horn Rocky Mo⑷tain
Canoec RchabtMMon towtltma f
Quality control is essential for client safety and Personnel issues and equipment selection are
satisfaction. Regular inspections of the workout important considerations in the operational plan.
area, exam rooms, assessment room、and bath Job descriptions help define the responsibilities
rooms are important. Inspections should include and expectations of employees in specific positions.
checking the cleanliness of air vents, workout equip Hiring qualified, personable personnel will keep
ment (treadmills, bikes, weight equipment, poles, clients returning to the program. Cancer survivors
bands, balls, spirometer), carpets, water fountains, wall come to the facility not only to seek enhanced
and so forth, because of clients' susceptibility to physical functionin系 but also because they may feel,
infection. Additionally, emergenev* procedures are for the first time since their cancer diagnosis，ttut
crucial (see chapter 9). they have some control in their lives. They enjoy the
A
Topics for Operating Procedures
for Cancer Rehabilitation Facilities
• Entry and dismissal of clients Maintenance and quality control
• Client records and charts Cleaning
• Billing and insurance Emergency plans
• Communication with heattti care profession Program assessments
als. clients, employees Prescription development and dissemination
• Facilities Exercise interventions
• Opening and closing procedures Changing and adapting to clients' needs
normalcy of their time at the facility and working by local, state, regional, and national health care
with healthy, happy personnel. and exercise organizahons. Programs shnuld follow
The most important personnel in the cancer reha published guidelines (e.g., Health/Fitness Facility
bilitation facility are the fitness professionals. These Standards and Guidelines from the American College
people need to recognize, address, and manage of Sports Medicine) Hut set the gold standards for
cancer-related symptoms; ensure the safety of each patient care. These guidelines use standards of care
client; promote a positive and supportive environ that address legal liability.
ment; promote adherence; help clients meet their The setting of the cancer reh«냐)ilHation facility
program goals during and following treatment; will affect the type of standards employed. For
adjust the exercise prescription and intervention to example, if the program is located within a hospital,
meet client needs; and monitor client progress and then the hospital's policies and procedure manual
communicate with clients, physicians, and other will dictate infection control, emergency manage
service providers. Of most importance is that the ment, and other policies. If the program is in a
fitness professional recognize the scope of practice aummuruh -based netting, a policies and procedures
when working with cancer survivors. Specifically, manual should be developed that addresses the
the fitness professional must know when and how management of the environment in relationship to
to communicate effectively with the mapr medical space use, acquisition of equipment, control of haz
specialties with whom cancer survivors may interact, ardous materials, prevention of injuries, safety train
including surgery, medical oncoiogy, radiology, psy ings and staff training for emergencies. The policies
chiatrists or psychologists, and dieticians. A fitness md procedures manual should contain measures
professional, for example, should not be consulting to ensure quality programs and the attainment of
on dietary practices nor medications to be taken. outcomes. The manual should also haveproevdures
Equipment selection should be based on the for information management—handling patient
clientele, be safe and dependable, offer variety, records, patient confidentiality, data storage, and
accommcxlate client volume and need, and be modi insurance billing.4 Lastly, pobcit*s and procedures
fiable. Equipment selection wiD also be based on the need to address assessment and care from the time
facility space and budget. Clients can use equipment clients enter the program until they leave.
similar to thcise in other fitness facilities with some The American College of Sports Medicine recom
modifications. For example, weight equipment often mends standards for fitness facilities that should
has weights that are too heavy for cancer survivors; also be standards for cancer rehabilitation facilities.1
these clients need extensive bahnee (Equipment (bal These standards Arv listed in the sidebar American
ance poles^ balance pads) because of potential neu College of Sports Medicine Standards for Health/
ropathies, lightweiît bands, balls, and lightweight Fitness Facilities.
dumbbells. As mentioned, equipment should be
cleaned after the workout of every cancer survivor.
Also, if at all possible, only cancer survivors should
be working in the workout area to avoid expensing
Legal Issues and
them to colds, flu, and coughing that could compro
mise their already compromised immune system藝 *
Documentation
To be comprehensive, a cancer rehabiUUtion Legal corufcideratkms should be a high priority in
facility will need to rely on ancillary services for the field of cancer rehabilitation. Management and
specialized expertise. These services may include employees should recognize the legal responsibili
massage therapy, <xxupational therapy, physical ties involved in rehabilitation. The fitness profes-
therapy, lymphatic massage, pain management, sionafs involvement in legal issues is associated
biofeedback, and psychological counseling. with the environment and the services rendered.
A strong management or operational, plan should
include high standards of care within all services
Policies and Procedures and cxinsistency among those delivering the services.
Within the operational plan, the management
Policies and procedures for cancer rehabilitation of the cancer rehabilitation program along with
programs should meet or exceed the standards set designated hwyers should develop a legal issues
American College of Sports Medicine
Standards for Health/Fitness Facilities
1. Facility operators shall offer a general proactivity screening tool (e.g., Par-Q) arxl/or specific pre
activity screening tool (e.g., health risk appraisal [HRA], health history questionnaire (HHQ)) to all
new members and prospective users.
2. General pre-activity screening tools (e.g., FVKR-Q) shall provide an authenticated means for new
members, anchor users to identify whether a level of risk exists that indicates that they should
seek consultation from a qualified healthcare professional prior to engaging in a program of physi*
cal activity. 효
3. All specific pre*activity screening tools (e g., HRA, HHQ) shall be reviewed and interpreted by
qualified staff (e g., a qualified health/fitness professional or healthcare professional), and the re
sults of the review and interpretation shall be retained on file by the facility for a period of at feast
one year from the time the tool was reviewed and interpreted.
4. If a facility operator becomes aware that a member, user, or prospective user has a known car
diovascular, metabolic, or pulmonary disease, or two or more major cardiovascular disease risk
factors, or any other self-disclosed medical concern, that individual shall be advised to consult
with a qualified healthcare provider before beginning a physical activity program.
5. Facilities shall provide a means for communicating to existing members (e g., those who have
been members for greater than 90 days) the value of completing a general and/or specific pre
activity screening tool on a regular basis (e.g., preferably once annually) during the course of their
membership. Such communication can be done through a variety of mechanisms, including but
not limited to a statement incorporated into the membership agreement of the facility, a statement
on the new-member pre-activity screening form, and a statement on the website.
6. Once a new member or prospective user has completed a pre-activity screening process, facility
operators shall then offer the new member or prospective user a general orientation to the facility.
7 Facilities shall provide a means by which members and users who are engaged in a physical ac
tivity program within the facility can obtain assistance and/or guidance with their physical activity
program.
8. Facility operators must have written emergency response policies and procedures, which shaJI be
reviewed regularly and physically rehearsed at least twice annually. These pobcies shall enable staff
to respond to basic first-aid situations and emergency events in an appropriate and timely manner.
Facility operators shaN ensure that a safety audit is conducted that routinely inspects all areas of
the faculty to reduce or eliminate unsafe hazards that may cause injury to employees and health/
fitness facility members or health/fitness tacility users.
10 Facility operators shall have a written system for sharing information with members and users,
employees, and independent contractors regarding the handling of potential^ hazardous materi
als. including the handling of bodity fluids by the facility staff in accordance with the guidelines of
the U.S. Occupational Safety and Health Administration (OSHA).
11 In addition to complying with al applicable federal, state, and local requirements relating to au
tomated external defibrillators (AEDs). all facilities (e g., staffed or unstaffed) shall have as part
of their written emergency response policies and procedures a public access defibnllation (PAD)
program in accordance with generally accepted practice, as highlighted in this section.
12. AEDs in a facility shall be located within a 1.5-minute walk to any place an AED could be poten
tially needed.
(continued)
171
American College of Sports Medicine Standards for Health/Frtness Faabties (continued)
13. A skills review, practice sessions, and a practice drfll with the AED shall be conducted a minimum
of every six months, covering a variety of potential emergency situations (e.g.. water, presence of
a pacemaker medications, children).
14. A staffed facility shall assign at least one staff member to be on duty during all facility operating
hours who is currently trained and certified in the delivery of cardiopulmonary resuscitation and in
the administration of an AED.
15. Unstafled facilities must comply with all applicable federal, state, and local requirements relating
to AEDs. Unstated facilities shall have as part of their written emergency response policies and
procedures a PAD program as a means by which either members and users or an external emer
gency responder can respond from time of collapse to defibrillation in four minutes or less.
16. The health/fitness professionals who have supervisory responsibility and oversight responsibility
for the physical activity programs and the staff who administer them shall have an appropriate
level of professional education, work experience, and/or certification. Examples of health/fitness
professionals who serve in a supervisory role include the fitness director, group exercise director,
aquatics director, and program director.
17 The health/fitness and healthcaie professionals who serve tn counseling, instruction, and physical
activity supervision rotes for the facility shall have an appropriate level of professional education,
work experience, and/or certification. The primary professional staff and independent contractors
who serve in these roles are fitness instructors, group exerase instructors, lifestyle counselors,
and personal trainers.
18 Health/fitness and healthcare professionals engaged in pre-activity screening or prescribing, in
structing, monitoring, or supervising of physical activity programs for facility members and us
ers shall have current automated external defibrillation and cardiopulmonary resuscitation (AED
and CPR) certification from an organization qualified to provide such certification. A certification
should include a practical examination.
19. Facilities shall have an operational system in place that monitors, either manually or technologi
cally, the presence and identity of all individuals (e.g.. members and users) who enter into and
participate in the activities, programs, and services of the facility.
20. Facilities that offer a sauna, steam room, or whirlpool shall have a technical monitoring system in
place to ensure that these areas are maintained at the proper temperature and humidity level and that
the appropriate warning systems and signage are in place to notify members and users of any risks
related to the use of these areas, including subsequent unsafe changes in temperature and humidity.
21. Facilities that offer members and users access to a pool or whirlpool shall provide evidence that
they comply with all waler-chemistry safety requirements mandated by state and local codes and
regulations.
22. A facility that offers youth services or programs shall provide evidence that it complies with all ap
plicable state and local laws and regulations pertaining to their supervision.
23. When a child is under direct staff supervision of a facility, as a participant in either an organized
activity or in an ongoing facility program, or is just under temporary staff supervision while the
parent or legal guardian is using the facility, the responsible staff person shall have ready access
to the child's basic medical information, which has been previously collected from the parent as
part of the child registration process.
24. The registration policy of a facility that provides child care shall require that parents or guardians
of all children left in the facility's care complete a waiver, an authorization for emergency medical
care, and a release for the children whom they leave under the temporary care of the facility.
172
25. The facility shall require that parents and guardians provide the facility with names of persons who
are authorized by the parent or legal guardian to pick up each child. The facility shall not release
children to any unauthorized person, and furthermore, the facility shall maintain records of the
date and time each child checked out and was dropped oft and the name of the person to whom
the child was released.
26. Facilities shall have written policies regarding children's issues, such as requirements for staff
providing supervision of children, age limits for children, restroom practices, food, and parental
presence on site. Facilities shall inform parents and guardians of these policies and require that
parents and guardians sign a form that acknowledges that they have received the policies, under
stand the policies, and will abide by the policies.
27 Facilities, to the extent required by law. must adhere to the standards of building design that relate
to the designing, building, expanding, or renovating of space as detailed in the Americans with
Disabilities Act (ADA).
28. Facilities must be in compliance with all federal, state, and local building codes (chapter 6).
29. The aquatic and pool facilities must provide the proper safety equipment according to state and
local codes and regulations.
30. Facility operators shall post proper caution, danger, and warning signage in conspicuous loca
tions where facility staff know, of should know, that existing conditions and situations warrant such
signage.
31. Facility operators shall post the appropriate emergency and safety signage pertaining to fire and
related emergency situations, as required by federal, state, and local codes.
32. Facility operators shall post signage indicating the location of any AED and first-aid kits, including
directions on how to access those locations.
33. Facilities shall post all ADA and OSHA signage that is required by federal, state, and local laws
and regulations
34. All cautionary, danger, and warning signage shall have the required signal icon, signal word, sig
nal color, and layout as specified in ASTM F1749.
Rap<in_d, by pemwMion taom Amencan Coiege of Sports Medcaw. 2012. ACSMW htgMItntt i，a_y Mandardi 離년 氣 «d.
(Ctwnpaign, Human 74-M
manual. Legal issues should be made known to informed consent from the client, although this more
all involved in the facility, and risk management readily falls under negligence. Informed consent
principles should be applied to enhance the qual obligates the facility and the fitness professional to
ity of service, improve client satisfaction, reduce present to clients the details, benefits, and potential
the probability of injuries, and reduce the chance risks of all proposed intervention strategies so they
of legal litigation. can make informed choices about participation.
Although laws affecting the rehabilitation staff A proper informed consent that details the risks
and the facility vary from country to country and and benefits of the program may be used as legal
state to state, fundamental legal principles apply to defense to claims on either contract or tort principles.
all. Two overreaching legal concepts, contract law Defense counsel would use the informed consent as
and tort law, are involved in the exercise cancer an assumption of risks of the phintiff. This, henvever,
rehabilitation setting. Contract law delineates does not excuse the fitness professional from acting
activities among indh-iduals. The basic contract in a competent and professional manner. An ethical
addresses agreements with the facility, agrwfnents component of informed consent is veracity, or the
with clients, and waivers and releases. obligation to speak and act truthfully.
An example of breach of contract for failure to A tort occurs when a person fails to observe
obtain adequate information would be not obtaining a duty of care or responsibility (negligence or
malpractice) that results in personal injury or death. clinics that are not connected to a hospital but have
This could involve defective equipment, hazardous the possibility of hiring a physician or physical
surroundings, or failure to properly supervise the therapists may be able to use the physician's or
client^4 physical therapists' provider number for reimburse
Currently no specific standards exist cancer ment. Diagnostic ccxies can be found online. Primar
exercise rehabilitation. However, there are stan ily, the facility should use the Medicare guidelines
dards for rehabilitation facilities and centers, such (section 2535) as the gold standard. Billing and
as the Manual of Standards for Rehabilitation documentation (e.g., SOAP notes: sub—rtive, objec
Centers and Facilities developed the US. Depart tive, assessment, and patient plan) requirements of
ment of Health and Human Services. The board third-party payers should be followed to receive
of directors <W a cancer rehabilitation facility may rvimbursetnent. Networking with cancer centers
want to seek legal advice about which standards and cancer treatment facilities can also help with
to use as guidelines for cUnical practice until stan reimbursenvRt4
dards are developed and accepted in the area of Local organizations such as a Susan G. Komen
cancer exercise rehabilitation. The best way to avoid Race for the Cure afftbate represent another avenue
circumstances that could result in litigation is to of securing funds for a cancer rehabilitation facil
operate according to practices that minimize the ity- Self-pay can also be explored, although many
risk of injury or negligence and ensure the safety cancer survivors have extensive medical bills and
of clients.4 so are less likely to self-pay unless they can be con
Confidentiality is important for all staff and vinced of the importance of exercise in their cancer
employees of a cancer rehabilitation facility. The recovery. Many ILS. state and federal agencies have
Health Information Portability and Accountabil grants for cancer survivorship (e.g., the American
ity Act (HIPAA) is a l丄S. federal law designed Cancer Society, the National Institutes of Health),
to protect the confidentiality of protected health which may be available to facilities involved in
information, whether it is oral, writtfn, or elec research.
tronic. A violation of HIPAA may have serious
consequences including disciplinary action, fines,
and imprisonment. Strategies to ensure confiden
tiality include assigning a number to the patient
Community-Based Support
to be used in databases; placing patient files in a Establishing a cancer rehabilitation facility requires
kicked file cabinet; identifying patients by number both public relations and marketing outreach to the
when using communication media such as e-mail; medical and lay communities. This outreach builds
requiring that all patient files remain at the facility; support, increases awareness, and creates positive
shredding patient materials; and using HIPAA attitudes. Once peciple in the community recognize
signature forms, which should be signed by all the need for a cancer rehabibtation program, they
staff, employees, and interns and kept on file for are more likely to participate.u,
prixjf that the facility is in compliance with the Successful cancer rehabilitation programs are
law.4 ▲ recognized and supported by physicians, especially
oncologists, who often refer their clients. Establish
ing a rapport with the oncology community will
Reimbursement C 매 cerns increase patient awareness of the services provided,

increase the chances of exercise intervention both
Exercise cancer rehabilitation is not yet recognized during and following treatment, and improve
by insurance companies as a category for reimburse cancer survivors’ attitudes concerning recovery.
ment. However, physical therapy and oncologists Cancer rehabilitation services should be clearly
can obtain reimbursement for their services (e.g., defined and communicated stressing the program’s
physical examinations, some assessments). Facili features and benefits to the cancer community.
ties that have a physician or physical therapist on Spokespeople for programs should emphasize that
staff need to obtain a provider number for billing. a majority of cancer survivors experience negative
In a hospital setting, the billing can be completed cancer treatment side effects and need help with
through the hospital billing department Outpatient their cancer recovery.
During the planning phase, program developers physicians can just sign after checking the services
identify the obicctives that would demonstrate pro they want for their patients.4 Communication with
gram effectiveness. Once program managers have the physician after referral depends on the physi
collected data on the effectiveness of the program, cian's preference. Some want to receive the results
they should present their data to the oncology com- of the as»e«i»inent5 and know how their patient is
munity in a short report that emphasizes specific tolerating exercise, whereas others do not want any
psychological and physiological benefits, potential information about their patients. Regardless of what
risks, research references supporting cancer rehabili physicians want regarding inforrruition on patients,
tation, and the qualifications of the staff. The pre programs should develop a charting form that out
sentation should leave no doubt in the physicians' lines the name of the cancer survivor, the date, and
minds about the benefits of the program to their the time of exercise to document any adverse events
patients. Additionally, the support of cancer sup that may have to be reported to the physician.
port group moderators, service organizations, and
clinical providers will help with program promotion.
Program promotion strategies include creating
brochures outlining the program and delivering
Summary
them to community oncologists and other health Cancer exercise rehabilitation program develop-
care providers. Follow-up calls to oncologists who ment includes four steps: a needs assessment, pro
received the brochure could be fruitful. Programs gram development program implementation, and
should also advertise in local medical newsletters, program evaluation. A mission statement, goals,
make presentations at local hospitals, and offer a and objectives should be established to ensure
week of free exercise for cancer survivors following quality care. Programs should be safe and admin
their treatment istered by certified and qualified personnel; they
Programs can make patient referrals very simple should provide appropriate exercise assessment,
and fast for oncologists and other physicians by prescription, and intervention protocols, as well as
developing a prescription pad (figure 10.4) that client education.
Figure 10.4 Sample Prescription Pad

Patient: _ Dale:
Diagnosis:
Rx
Atness assessment and exercise prescription D Flexibility and range of motion
D Supervised cancer exercise rehabilitation program C Balance and agility
Cardiorespiratory endurance ᄃ Water treadmill
Muscular strength and endurance ᄃ Nutritional analysis
□ Other (please explain): '
I deem this Rx medically necessary.
Physician or primary care: MD/DO/PA/CNP
Printed name:
Telephone number:
From ACSM, 2012, ACSM's gutO» Id Marose and cancer survivonhip (Champaign. IL. Human Kmeiea). Actapted. by peanission. trom Rocky Mo네tain
Cancer Rehabilitation Instftule.
Once program preparation is complete, develop Wolters Kluwer/Lippincott Williams & Wilkins;
ers should establish budgeting, program pricing, 2008.
and marketing plans, followed by evaluation proce 3. American College of Sports Medicine. ACSM'i Rtiourct
dures. Evaluation is essential to ascertain the effec Manual far GuuMintsfor Extrdst Testing and Prescription.
tiveness of the program and whether the program 3rd ed. Baltimore: WilliAfra & Wilkins; 1998.
and financial objectives are being met. Programs 4. Schneider CM, Dennehv CA, Carter SD. Exercise
should include behavior modification and exercise and Canctr Recovery. 1st ed. Champaign, IL Human
Kinetics; 2003.
programming that emphasizes initial, improve
ment, and maintenance phases. Quality control is 5. Schneider CM, D^nnehy CA, Roozeboom M, Carter
essential to ensure client safety and satisfaction. SD. A model program: Exercise intervention for
cancer rvhabiliUtion. hiiegr Cancer Ther. 2002; 1(1):
Policies and procedures should meet or exceed the
76-«2.
standards set by local, state, regional, and national
6. U.S. Department of Health and Human Services,
health care and exercise organizations.
Centcre for DiwaMT Control tntfVnrxtfntion. Physical
Finally, establishing a cancer rehabilitation facil
Actiinty Evaluatkui HandbMh. http://www.cdc.gov/
ity requires both public relations and marketing nccdphp/dnpa. Updated 2002. Accessed September
outreach to the medical and lay communities. There 25,2009
are many strategies for effective administration; 7. Deming WE. QutfKy, Pmductiinty, and Compttitiw
fitness professionals need to determine the best Position. Cambridge, MA: Massachusetts Institute of
strategy for their clients and their communities. Technology, flBcilitv for Advanced Engineering Study;
This chapter provides a starting place. WR2.
8. Grantham WC，Patton RW, York TD, Winiek ML.

References Health Fitness Management. Champaign, IL: Hunun
Kjflvtio*, 1998.
1. Kaplan RJ, Van Zandt JE. Cancer rehabilitation.
eMedicine Physical Medicine and Rehabilitation. 9. American College of Sports Medicine. XCSMs Health/
http://cmedicinc.mcdscape.com. Updated 2009. Fitne於 Facility Stamlards and Guideline、3nj ed. Cham
Accvssed September 24,2009. paign, IL: Human Kinetics; 2007.
2. DeVita VT, Lawrence TSZ Rosenberg SA. Canctr 10. Kotler R Marketingfor N(mpnfit Organizations. Engle
Principles 分 PracticfcfOncology Sth ed. PhibdelpMa： wood Cliffs, NJ： Prvnticc Hall; l9z5.
Appendix
ACSM/ACS Certified
Cancer Exercise
Trainer
Job Task Analysis
Exercise Physiology and Related Health Appraisal, Fitness, and
Exercise Science Clinical Exercise Testing
1.1.1 Knu^'ledê of physiologic outcomes that may 13.1 Ability to obtain a basic history ivganiing cancer
be improved by exercise training among cancer diagnosis (e.g., type, stage) and treatment (e.g.,
'survivors. surᅤtries, systemic and targeted therapies).
LI .2 Knowledge of symptoms and psychological at 13.2 Knowledge of and the ability to recognize the
tributes that may be improved by exercise traio- adverse acute, chronic, and late effects of cancer
r k ing among cancer Mirvivon. treatments.
1.1.3 Knowledge of lymph, immunologic, cardiac, 133 Ability to obtain medical history for other health
neurologic, and hematok)gk systems as they conditions (e.g^ neurological, cardiovascular;
pertain to cancer-sped fie exercise muMuloskcldaL pulmonary) that may cooccur
and interact with advene effects ot cancer tivat-
1.1.4 Knowledge of acute and chronic effects of exercise
ments.
on temperature tvguiation and the adverse ther-
morcguhitory /vasomotor symptoms (e.g., hot 13.4 Knowledge of and ability Io discuss physiologic
fla公he이 experienced by many cancer survivors. systems affected by cancer and treatment and
how this would affect the major components of
1.1.5 Knowledge of cancer diagnosis and treatment
fitness, including bahnee, agility; speed, flexibil
effects cwt phy»k)k)(cica! nrepcinsic to Acuta* and
ity, endurance, and »tivngtK
chronic exercise, particularly with regard to phys
ical deconditioning, body composition changes, 135 Knowledge of how cancer and its treatments
and range of motion. may alter balance, agility, speed, flexibility,
177
178 Appendix
endurance, and strength in cancer survivors and Nutrition and Weight Management
ability to select/modify And intcqxvt tv»ts of
13.1 Knowledge of common effects of cancer treat
these fitness elements.
ment on energy* balance and body composition
1.3.6 Knowledge of how cancer and its trvatments for individuals with nonmctastatic disease.
may affcrct body composition in cancrr survivors
1^.2 Knowledge of effects <W cancvr cachexia on en-
and ability to select/modify and interpret tests
eigv balance, iftUkc, and activity level among
of body composition in cancer survivors.
individuals with metastatic disease.
1.3.7 Knowledge of categoriv* of pativnb* that rvqutre
\A3 Knowlvd^ of rvlattonUiip betwevn body com.
medical clearance prior to testing or exercise pee*
position as a risk factor for the development of
scription.
some cancers, and pos&ibly as a risk factor for
1.3.8 Knowledge of cancer-spvcific tvlative and abso uuwer rveumnee.
lute contraindications to exercise testing.
1.8.4 Knowledge that many cancer survivors may use
eompicmcnUry «>nd alt«?mdtivc medicine (CAM)
Exercise Prescription and •ppruachek, and of the potential for these rvm.
Programming edks to influence exercise testing and prescrip
tion parameters.
1.7.1 Knowledge of current Amerkan Cancer Society
guidelines for exefeise in cancer survivors. 1^3 Abibty to identify unintentional weight change
that may relate to disease status, and recom
1.7.2 Ability to describe benefits and risks o£ rxendse
mend that the client seek appropriate medical
training in the cancer survivor.
attention.
1.7.3 Ability to recognize relative and absolute contra
1K6 Know ledge of effect of chemotherapy and radia
indications for starting or resuming an exerviM?
tion on the mouth and gastroinlntirul system,
program, and knowkdgc it is nvcvM^try
and the r«>ult of ktu*sv changes an appetilv and
to refer participant back an appropriate care
food preferences and choices.
provider. y
13.7 Ability to diw^m when a participant's nutrition*
1.7.4 Knowledge, skill, and ability to nuxiify exercise
a) questions or btitus would be best managed by
prescription / prugram baêd on:
referral to a registered dietitian.
a. current nwdtcal condition
1A8 Knowkdgc o, current American Cancer Soci
b. time since diagiuwii* on or off adjuvant
ety nutrition guidelines during and after cancer
treatment
treatment.
e Wpe of current therapies (e.g., no swimming
during radiation) 1A9 Knowledge of hydradon ru*vd» specific to cancer
patitmts and survivors.
d. type and recency of surgical procedure公
(e.g., curative or reconstructive} 1.8.10 Knowledge safety of weight loss programs for
e. nnge of motion cancer survivors.
f. presence of implants
g. amputdtiims/fu&ions Human Behavior and Counseling
h. effects of treatment on all elements ut fitne변 1.9.1 Knowledge to identify a teachable moment for
(agility, speed, coordination, flexibility,, cancer survivors and ability to use that time to
strength, and endurance) provide appropriate information and education
i. hemat»k>gic ainsideratiorts (e.g., anemia, about re»unung or adopting an exercise pn>
neutropenia) gram-
pnestfnev of» central line (PIC or Port) 1.9.2 General knowledge(4 p»ycho-»ocial problems
k. current adverse effects of treatment, both common to cancer survivors, such as deptv&&ion,
acute and chronic anxiety, fear of recurrence, sleep distuxbances,
body image, sexual dysfunction, and work and
l. individuals that may be at inervased risk lo『
marital difficulties.
advene late effects that could inervase risks
associated with exercise (e.g., heart failure) 1.93 Knowledge of behavioral strategies that can en
1.7.5 Knowledge of potential for overtraining with the hance motivation and adherence (e.g., goal set
cancer survivor. ting, exercise k>않、planning).
1.7.6 Knowledge of and ability to use appropriate sun 1.9.4 Knowledge of the impact of cancer diagnosis
protection for outdoor pmgrjmming. and treatment on quality of life (QOLb and the
Appendix 179
potential For exercise to enhance a range of QOL cancer-related protected health information of
outwmes for sunivors (e.g., »lvep, htigue, and participants.
other factors).
1.11.5 Knowledge and abiHh* to obtain referral from
1.9.5 Knowledge of and ability to determine effective physician and communicate with physician
ness of gmup exercise programming vs. individ* about adverw events, abilities* and limitations of
ual exercise to meet dienfs needs. survivor, and outcomes of testing and training.
1.9.6 Knowledge of how cancer and cancer treatment 1.11.6 Ability ID recommend appropriate websites and
rvlate to ability and rvadineM* to start an exercise reier toother health professiofuk.
program.
1.117 Knowkdge of rvimbursement programs as eli-
1.9.7 Ability to hciiitalc the social support needs that gible /availablf.
arv cancvr specific including connections to web
sites and local support groups.
Clinical and Medical Considerations
1.1Z1 Knowledge of the nupr long-term effects of
Safety, Injury Prevention, and treatment among childhtxxi cancvr survivors
Emergency Procedures that may require careful screening and program
adaptation for these individuals.
1.10.1 Knowledge of and ability to recognize and re
spond to cancvr-specific safety issues^ 齡uch as 1.12그 Knowledge of the conuru)n bide effects* and
susceptibility to infection, musculiMkeletal and symptoms ot typical cancer treatments (surger
orthopedic changes, unilateral edema, fatigue, ies, chemotherapy, r^dution, hormone manipu
lymphedirma, neun»k»gical changt*, <»hH»pon> lations, other drugs).
sis, cognitive dedine assodat^d with treatment.
1.123 Know ledge that ameer treatment may accelerate
1.102 Knowledge of and Ability Io rvspond to cancer functional decline aRsocUtvd with aging, partic
specific tffntfrgencM*»# Including：, sudden Iom» of ularly in the vlderly; and that exercise prvgram-
limb function, £e\'er in immune-inoMnpetent pa* mii방 may need to be adpsted accordingly.
tient and menu! status changes.
1.12.4 Knowledge cW the combined effects of aging and
1.103 Knowledge of and ability to ivspond to the cancvr treatment on exercise capacity and selec
signs and symptoms of new-onset and major tion of appropriate testing modalities and inter-
life-thraalcfung complications of cancer, such as pivUHon of nrauits.
»up(<icw vena cava «yndn)me (SVCS>, M*p«is or
infection, and spinal cord compression. 1.123 Knowledge of the common sites of metastases
and ability to design and implement appropriate
1.10.4 Knowledge of and ability to write up incident exercise programs comistmt with this knowl
docunwntation related to cancvr specific advene4 edge
events.
1.126 Knowledge of the signs and symptoms associat
ed with ncw-<]nset lymphedema and the nujor
Program Administration, Qualify cancer type» asscxziated with incrvased lymph
Assurance, and Outcome Assessment edema risk (eg., breast, head, and neck cancer).
1.11.1 Knowledge of role in AdministratMm and pro 1.12*7 Knowledge of National Lymphcdenw Network
gram management within a cancer center, cancer (N1_N) IS risk reduction practices, and exercise
treatment facility, and outpatient setting. guidelines.
1.11.2 Knowledge of the type* <W exvtxiiie programs 1.12<8 Knowledge o( how cancer trvatnwnt may alter
available in the community and which of the표e cardiovascular risk factors, and inappropriate
programs cater specifically to the needs of cancer cardiovascular responses to exercise testing or
survivors. training.
1.113 Knowledge of and ability* Io implement effec 1.1Z9 Knowledge of lymphatic, neurological, and im
tive, professional business practices and ethical mune system factors in cancer survivors that
promotion of pcrwnal training services to tfw may rvquirv further evaluation by medical or al
cancer can* community (eg., physicians，nurses, lied health professionals before participation in
social workers, physical therapists, survivors physical activity.
and their families).
1.12.10 Knowledge of how common cancer treatment
1.11.4 Knowledge of the Health Insurance Portability affect the ability of cancer survivors to perform
and Accountability Act (HIPAA) and ability to exercise, and how to adjust programs accord,
implement systems to ensure conftdcntiality ingly.
180 Appendix
1.12.11 Knowledge of the effect of cancer treatment on recommend that clients seek additional medical
bahnce and mobility and the ability to develop evaluation.
an apprupriate exercise program that minimizes
1.155 Understand typical durations o< cancer therapy
fall/injury risk
for the major cancers (breast, prostate, melano-
1.12.12 Knowledge and ability to recognize the limits in m屬, ovary, lung, colon), and that therapies an?
the scope of practice for exerdse professionals continually evoivin容/changing.
in working with cancer surv ivors with complex
medical is»ues. 1.15.6 General knou'lcdge of current cancer trvatment
strategies, including surgvry, systemic thera
pies (e.g., chemotherapy) and targeted therapies
Physiology, Diagnosis, and (e.g’ anti-angiogenesis inhibitors).
Treatment 1.15.7 Knowledge of how lifestyle factors, including
1.15.1 Knowledge of currently accepted screening nutrition, physical activity, and heredity, influ*
practices for surv eillance of recurrence for com- encr hypothesizixj mechanisms of cancer etiol*
num cancers (e.g., mammography, cokMioscopy,
▲ '
prostate specific antigtrn, pap smears).
1.1 도8 General knowledge of the descriptive epidemi
1.15그 Knowledge of the pathology tests used to di- ology of cancer, including the prv\alcnce, inci
agnow axnmon cancvrs (e.g., biopsy, imaging dence. and stfnuval statistics for the mapr can.
technologies, and blood tests for tumor mark cer types.
ers).
1.15.9 General knoMvdgc of cancer biology《eg., initi*
1.153 Knowledge of how to a>mmun»cate efh?ctively ation. prxMm)tu)n /progxvsbicvn, and meUMas^s),
with the major medical specialties with wham paiticularly for the four most common cancer公:
cancer survivors may interact including sur lun^, brvast. coion, and prostate.
gery, medical oncology, radiology, dietitians, and
psychologists/psychiatnsbL e Americ«i Coftage of Spom Medkane 2008 Al ng_ rmerved
www.aesm.org.'AM/Template.cf m?Section=ACSM_ ACS_Cer-
1.15.4 Knowledge of the most common warning signs MbmI Cancer Exercise_Trainer&Templates/CM/ContentOtsp4ay.
dmlCcn_nr«，O，2173
of rccufrence for common cancers, and when to
Index
Note： The italicized/and t following page numbers refer to figures and tables, respectively.
A American Institute for Cancer bone loss

ACS. Str American Cancer Society Research (AICR) 114,115/ assessment of 131
ACSM. See American College of American Joint Committee on Cancer cancer treatment and 22,67
Sports Medicine (AJCC) 34 exercise prescription and 67-68,
active listening skills 143 amputations 101-102,156 104, 111
acupuncture 23 androgen deprivation therapy (ADT) injury risks and 22,93,103-104
adiposity, body composition and 123 23,5^0,61,67 medications for 67-68
aciiuvant treatment 7,103 anemia 66,101 nutrition and n5t. 131-132
ADT (androgrn deprivaben therapy) Ann Arbor classification system 5,5t nsk factors f6r 131
23,59-60,6b 67 anorexia 117,118 brain cancers 66,155
aerobic exercise anthracydines 21,65 breast cancer
after breast cancer 109 aphasia 155 body composition and 61
blood cell counts and 103 arm span mcaMirement 122*123,123f bone health in 67
cardiorespiratory fitness and 51 aromatase inhibitors 6, 22-23, 61, cardiorespiratory' fitness and 51
CVD risk factors and 65 65,67 energy restriction and 125
fatigue and 62,106 arthralgia 22-23,67,1(M exercise and 23,34-35,361.5115氏
guidelines for W-90, ^4 assessments, prior to participation 92-96
hematological effects of 66 166,167068/1 exercise contraindications ^2-93
joint stiffness and 23 hematological effects of exercise
B
safet)- and efficacy of 51/ and 66
aerobic fitness 55-56 back pain 25,155 HER2/neu 8,16
age-predicted heart rate tests 80f, 81 balance 65,79,84,157 hot flashes and 66必7 ,
aging acceleration 100, W2 basal cell cuonoina 24 immune function and 64
AHA (American Heart Association) behavior chainge counseling. See injury risks 93
»，115/ health behavior change coun- lymphedema and 7,23,63-64,95,
sding 101 Mb/
A1CR (American Institute for Cancer
R*-M*.irch) 114,115( bet>-Cir(Mcnc 39-40 lymph node rcmovd in 101
AJCC (American Joint Committee on N_《 174 obedK tod 30,30f, 31,331,116
Cancer) 34 biotnarkers 130-131 prevalence of 2,36 10
alcohol 39,115T, 127,133-134 bisphosphonates 67-68 pulmonan- changes and 21
Amencan Cancer Society (ACS) bkotnycin 21 Equality of life and 61-63
on dietary supplements 40 교 blood chemistr>, 10X 1CM-105, 1 JO- resistance training and 59,60
on exercise 89,91 131 risk factors for 39,61,128
on fatigue and cancer 106 board of directors 162*163, sample exercise prescription for
on nutrition 115f body composition 1(公410
on screening 5,6/ adiposity and 23,61,123 screening for 6t,7-8
on support grou(_ 150 assessment of 75, 123-125, 12^ survival rates for 4f
Amencan G)llcgr(>f Sports Medicine 125( treatment of 7-8,100*1 이
(ACS exercise and 51/, tl triple-negative 16
certification of trainers for people resting metabolic rate and 126 yoga and 61,95
Hith dlabilities llC body fat 23^ 6k 123-124 breast cancer-specific scale (FACT-
on enntraindications to fitness test- bexiy nuw index (BMI) 30,1221,123. B) 61
ii않 法*於，S3f S<roiso obesity breast reconstruction 100*101
exercise prescription of 89 body weight. Srr also obesity business managers 163*164, \63f
facility standards of 171-173 assessment of 75
on flexibility exercise 89 cancer and 30-33,33/ C
on rehabilitation programs 170 Hamwi estimation 122-123 cachexia 117,118,128
on resistance training 59 recommendations for 115f, 122/ calcium, bone loss and 131
rcmndtablc guidelines of 50,54-55, underweight 117-118, 1221, 123, CAM (complemenUry altenutive
56,91-95 126,128 medicine) 132
American Heart Association (AHA) weight dunge calculation 121 cancer. Ser also side effects of treatment
w，n어 bone cancer 156-157 biology of 2-3
181
182 Index
cancer. Stealso side effects erf treatment administration and methodology contingency phns, facility 157-158
(continued^ of 8MSr Mr contract Law 173
bone loss and 22,67,131 eligibility criteria and client sdec- coordination, treadnull tests and 84
diet and 3740,114,127 ti、、n ＜、“、사 corticosteroids, infections and 154
exercise contraindications after follow-up phone call after 84 CPET (cardiopulmonary exercise
(신씨 maximal vs. »ubmaximal 79•必 1, test) 80f
exercise effects on 33-37,36/ 80t,82 C-reactive protein 65,130
incidence and survival rates 1겨. 美f Physical Activity Readiness Ques cycle ergometer tests 83-^4,8^
median age of diagnosis of 50 tionnaire 75,76( cytokines 100
nutrition and 125*126,128 puqxise ot 81-82
obesity and 30-33,33f. 116-117 sequence of procedures 74-75 D
recurrence 12,24-25,35,39,105 setting for S2. DCIS (ductal carcinoma rn situ) 7
risk mechanisms 32,33f, 36,36/, 39 cardiovascular disease decondihonmg 62
sUging system for 3-5,4f, St after treatment 16,20*21,65,114 dehydration 131
time periods in 99,99f nutrition and 115/ depression 63,120
cancer prevention from renal damage 24 DETERMINE acronym 120*121
body weight and 30,30f, 32,116* cardiovascular syslem 65 diet See nutrition
117 central lines 103 dietary supplements 3*M0,115(，133
dieUrv recommendations for 40, Certified Cancer Exercise Trainers directors, program 163,163^ 164
114*115,115/ 162 Dirty Dozen" 129
exercise and M 35,36-37 cervical canoer 61,30 UiiMibiKtitfs, exercise and 90
cancer rehabilitation programs 162- charts, client 167( distress, from cancer experience 143-
175 chemobrain 22. Set also cognitive ， 144,150
client initial asKCJismcnt 166, U公f, impairment doctors. Str physicians
168^16^ chemotherapy documentation 158,174
conununih -based support for 174- aerobic exercise during 55,56.103 dose-response effects of exercise
change from 20-22,24^4-65, 34,35
confidcntiality in 174 67 、鐘S广 dragon boat racing 95
equipment selection in 170 cognitive impairment from 22,104 dry mouth 119
financial statements for 164 immune function and 64,154,155 ductal carcinoma in îtu (DCIS) 7
fitness focilitv standards and 171- quality (W hk and 61-63
173 resistance (mining and 60 E
legal issues 170,173-174 tuning of fb, 99-100 edema, unilateral 137
management of 164-165 children, as cancer sunivors 22,24 eligibility criteria B2-S3,83f
mission sUtemcnt of 162,163 chiikflleml 65,127 emergency pmettiurrs 157-158
needs assessment in 162 cisplatin 22,103 endocrine ftkle effects 22
objectives of 162,163 *Oean 15" fruits and vegetables 129 endotn drial cancer
organizational structure of 162- cleaning checklist for facilities 15y oififciscand 35,361
1M, 16^ client clurS lb6, 1 卜 obesity and 30, 과 31-3X 331
personnel in 169-170 clinical coordinators 16작, 164 screening for 61
policies and procedures 170 Clinical Laboratory Improvement energy-dense diets 37
program description and opera Amendment (C.L1A) 131 energy requirements 31,125-126
tions 166-17D, 173 cognitive impainnent 22,104,14Z156 equipment selection 170
program development in 162,164 aôn cancer. Sfealso colorectaicancer enlnropoietin 103
program evaluation in 164, 1651, exercise and 34, ★ ML 含V, 92-95 esophageal adenocarcinoma 30,30f
exercise contraindications after 32,331
艾『 estrogen, hot flashes and 66-67
injury risks 93 exercise
174 obesny and ?0,30f, 31,33f benefits Io cancer patients 36,36f,
settings for 165,170«173 red meat and 130 51696
target population for 165-166 colorectal cancer bone health and 67-68
cancer-related fatigue 103. Sec alsc diet and 37,38-39 breast cancer and 23, 34-35, 36t
fatigue gastrointestinal changes aftrr 23 51t55,92-%
cancer screening 5-11, (st, 24 obesity and 30,30f, 31,33f cancer medications and 66*68
cancer survivors, definition of 90 prevalence of X V V cancer prevention and 36-37
caibohydrates 127,1341 screening for 61,11 cardiorespiratory fitness 51,54-99,
carcinoma，defined 2 community-based support 174-175 y7f-58f
cardiopulmonary exercise test complementarv alternative medicine cardiovascular health and 65
(CPET) 80T (CAM) cognitive impairment and lOt, 142,
cardiorespiratory fitness 51, 54-59, compression sleeves 63-64,157 156
5꾸와 oonftdentiality 173-174 endometnal cancer and 35,36t
cardiorespiratory fitness testing congestive heart failure 20-21 fatigue and 62,106,142
ZM5 consUnt load test 80f fev ers and 154-155
Index 183
flexibility 51/, 6061，99,95,102 expanders 101 gynecological cancers 51192-95

frequency and intensity of 54-55
goals of 89-92,105-106,149, )49f H
guidelines on 54-55,88-90 facilities. See also cancer rehabilitation Hamwi estimation of reasonable
hematological system and 66 programs .ht 122-123
hot flashes during 67 contingency phns for 157-158 hand washing importance of 10X
immune system and 64,102*103 facility cleaning checklist 155f 154 >5
joint pain and 67,104 factors in dev eloping 165 head and neck cancers
lympnatic system and 63-64 inspections of 169 alcohol and 처
neuropathy and 65-^6,104,156 FACT-B (breast cancer*spccific scale) hydration and 131
outcome expectations 145,146 61 hypothyToidism and 22
physiological effects of 50-51, FACT-G (function assessment of ^resistance training and 59-60
M-99 cancer therapy scale, general) 61 salt and 39
previous intensity of 55,157 fad diets 128-129 surgery for 100
program duration 54 fast foods 37-38 health behaxior change counseling
prostate cancer and 35-36,36/, % fatigue 141-1 비
quality of life and 61-63 ACS on 106 goal setting in 149, Wf
readiness for 75, 76(. 14그.144,147- Wood chemistry and 102-103 sodal cognitive theory and 144-
148,148f from cancer treatment 19-20,100, 146,145<
slow progrvs&ion of 56,165-166 li 나 142 K support groups 150
social cognitive theorv and 144- contributing factors in 19,142 theory of planned behavior and
146,145f exercise and 62,106,142 146
specificity(났 training 56,59,60 Fatigue Symptom Inventory \G7f- translating theorv into practice
timing cn 54,55-56
treatment liming and 99*100
乂몌
iitferventions for 19-20
147-150,14^
transtheoretical model and 146-
during treatment us. after treat ov ertraining and 105-106 147,14ᄍ 148f
ment 50-51,55-56,165 taiety and treatment effects and 142*144
Exercise and Energy Weekly Log tracking 56,57f, 106 Health Information Portability and
55-56,57f-5tf fats, dietarv 37-38,123,131, lUt Accountability Act (H1PAA)
Exercise Center intake Form FDA (U.S. txxxi and Drug Adminis
exercise prescriptions tration) 133 health screening. Str medical history
ability of client and 1Q2,166 fearfulness 144 height measurements 122-123,12y
ACSM/AHAon 809,92-93 fevers 154 Helicobacter pylori (H. pylori) 39
ACS on 8^91 fiber, dietary 38-39,127 hematologic cancers 51,511,92-95, %
aging acedmbon and 100,1Q2 financial statements, program lb4 hematopoietic stem cell transplants*
amputations and 101-102 fitness assessments 51, M-39,166 tion(HSCr)1-5.5H,
blood cell counts and 102-103 fitness facility standards (ACSM) HER2/neu breast cancer 8,16
for cancer sunivors 90-95 171-173 high-cak>rie foods, cancer risk and
central lines and 103 fitness professionals, role of 170 37-38
contraindications for 92-93, 104- flexibility exercise 51t 60-61, 89, HIPAA (Health Information Porta
105 95,102 ， bility and Accountability Act)
current medical condition and 97 fluid iu*uds 13! 174
iatii；ueand 62,105-106 folate (folic acud) 39,133 Hodgkin's hmphoma 21
food safety 130 Home Exercise Log 58f
goals of 92,105-106
individualization of 91,96-97,166 frequency of exercise 54-55 hormonal therapies
ostomies and 103 fruits 38,3St. 127,129 injury risks and 93
peripheral neuropathy and 65-66, functional foods 132 menopausal 66
104 J56 function assessment of cancer ther side effects of 19f, 22,67
physician consultation and 75,91, apy scale, breast cancer-specific sleep dysfunction and 142-143
97 (FACT-B) 61 timing 99
range of motion and 101 function assessment of cancer ther in treatment 16
for resistance exercise 59, 60, 89, apy scale, general (FACT-G) 61 hormones, cancer and 7-8,33t
94-95 hot flashes 66
samples of 109-110, 111 HSCT (henutopoiebc stem cell trans
surgery and 100-101 gallblad der cancer 30 plantation) 1-5,51L 64,92-95
time since diagnosis and 97,99 gas exchange collection 7% 81 hypothyroid ism 22,123
treatment effects and 10105,166 gastrointestinal side effects 23
treatment timing and 9分400 Gerson diet 133
U.S DHHS on fo-90, 乂95 Gleason score 8 IGFs (insulin-like growth factors)
exercise risks. Str also safety goal setting 105-106,149,14’ 150 32,331
injuries W graft*versiis-host disease (GVHD) 24 immune system
overtraining 94,105-106 Grantham model of quality manage biomarkers of 130
risks of inactivity and 89-90,91 ment 165 cancer trvatinent and 23,64,99,102
184 Index
immune system (continued) lymph 63 muscular strength and endurance.

exercise and 64,102*103,104 lymphatic system 63-64 Sec resistance exercise
hematopoietic stem cdl transplants lymphedema musculoskeletal changes 22-23
and 105 asking clients about 157 mutations, cancer and 2-3,10-11
inactivity, avoiding 89-90,91 breast cancer and 7,23,63-64,95, myeloma 2. See 着/so multiple
incident reporting 158,159f 101 myeloma
indwelling catheters 103 compression sleeves and 6344 myocardia) Infarction 21
infections 93,154-155 exercise and 63-64,144,157
N '
inflammation fear of 144
cancer treatment and 100 gynecologic cancer and 95 Natfonal Cancer Act of 1971 162
C-reactive protein and 65,130 injury risks and 93 hfotional Cancer Institute 162
diet and 38 resistance training and 59,104 National Comprehensive Cancer
physical activity and 36 lymph nodes 7,9,100-101 |kJlctworic(NCCN) K, Im. 24
iniormed consent 173 lymphoid neoplasms 4-5,5^ Kahonal Health Association 115f
infrared interactance 124 lymphomas 4,20,21,55 National Lymphedema Network
Initial Assessment form I67f wdMhe 川 1
injury risks 93,96 M natural kilkr (NK) cells 64
inspections, facility 169 macrobiotic diet 13^< nausea 118
Institute of Medicine (IOM) 18,19, macronutrients 127*128,134/ NCCN (National Comprehensive
127,128 MAMC (mid*arm muscle circumfer- Cancer Network) 8, IM, 24
insulin, in cancer and obesity 32, etuc) 124-125, ! needs assessments, program 162
33/, 65 mammog^phv 7,8 negligence 173
insulin-like growth factors (IGFs) Manual of Standards for Rehabilita- neurological side effects 21 -22,65-66.
32,33t ÂiCailen and Fauhiu、' l、 Sec also peripheral neuropathy
insurance reimbursement 174 DHHsi 174 neuropathic pain 20
intensity* of exercise 34,54-55,56,64 master)rexpenenoes 145,145^ 14汝 149 neutropenia 66
intention 146 maximal cardiorespiratorv exercise new client treatment form X7fA9f
interferon, aignitive functuxi and 142 tests 79,80t 84-85 911, calling 1 明
interstitial brachytherapy 9 meats 39,130 nodcqptive pain 20
IOM (Institute d Medicine} meat substitutes 130 nonoHcxigkin s lymphoma 30,116
127. 12M medical attention, need for 105 non-smaU ceU lung cancer (NSCLC)
medical directors 163,163f VW
medical history nutrition
job descriptions 169 current condition assessment 97 assessments of 120-121,166
joint pain 22-^, 67,104 in exercise center intake form 52^5^ biomarkers 130*131
in initial assessment 166, l€7f cancer and 37-40,-M¥： 114-115,1151,
in testing sequence 75 128
kidney cancer 30,3^32.33/ Medicare 174 in complementary alternative
k-ras eenc 10-11 medications 66-68, 77f-7Bfr 121. Set medicine 132
Kushi, Michio 133 also speafic medications dietar\r supplements 39-40,115f, 133
memory loss, nutrition and 120. Set energy requirements 125-126
tho cognitive impairment factors in 120-121
left ventricular ejection fraction menopausal hormone therapy 32 fad diets and 12B-129
(LVEF) 65 metallic rate See resting metabolic food safety 130
issues 170,173-174 Alte fruits and vegetables 38,381,127,
leisun^tiinc activities 34,36 metabolic s)*ndn)me 65 129
leukemias 2,3^4,30,116 metastasis functional foods 132
lifestyle factors bone loss and 156 Gerson diet 133
body weight and 30-33,33/ in cancer types 8,9,10,11 hospital length of sUv and 126*127
diet and 37-40,38t40f definition <x 2 inatrnbintK dirt 133
exercise effects and 33~37,36t injury risks and 93 macronutrients 127-128,1SW
listening skills 143 physical activity and 50 nutrient-dense diets 117,127
liver cancer 30,39 warning signs of IX 67 organic fcxxls and 129
liver damage 25 methylphenidate (Ritalin) 20 pesticides and 129
LiveStrong website 18 mid.arm muscle circumference plant-based diets 127
lung cancer (MAMC) 124-125,12V water and hydrabon 131
beta-carotene and 39-40 Mifflin-St. Jeor equation lz6 whole grains 130
prevalence of milk, fat content of 131 Nutrition Screening Initiative 118
resistance training and 61 mission statements 162.163
screening for 5,9-10 modeling 145,14^ 149 O
treatment of 10-11 mouth pain 119,121 obesity
types of 9,10 multiple myeloma 30,93,103,116 abdominal 32
lycopene 38,38/ muscle atrophy 156-157 oincer mechanisms and 32,33f
Index 185
cancer occurrence and 30,30f, 116- recommending clients see 105,158 readiness to exercise
117 referrals from 174-175, \75f assessment of 75,76f
cancer prognosis and 30 sample prescription pads for \75f in beh雇vio『 change counseling
Physiaani Permission Form 98f 147-14公，14사
in cancer survivors 116
cancer types and 30, JOf, 31-32 physiological and affective states cancer effects on 142-144
classification of 30,122/, 123 \45f, 146,149 record keeping 158,174
older adults phvtochemicals 134/ rectal caoter 31. See also colorectal
ACSM/ AHA exercise guidelines 89 PIC lines 103 cancer
agin^ from treatment in 100,102 pibtes 95 recurrence 24-25,35,39,105
cognitive function in 142 plant-based diets 127 red meat, cancvr risk and 39,130
dehydration in 131 pneumonitis, radiation 21 registered dietitians (RDs) 114,126
exercise goals of 91 policies and procedures 170 rehabilitation programs. See cancer
nutritional health of 121 Presenting the Cancer Survivor to the rvhabiliUtion programs
US. DHI is wercise guidelines 90 Physician reimbursement concerns 174
omega-3/omega-6 fatty adds 128 processied meats 39 renal cell carcinoma 30,30f 32
1 •repetition maximum (1RM) test process evaluation 164 renal damage 25
59,60 program administration 161-175. resistance exercise
operational plans 166,16^-170,173 See also cancer rehabilitation ACSM/AHA guidelines for 89
organic foods 129 programs after breast cancer surgery 59,
organizational structure of staff 162. program ex aluatitfn IM, IftSt 175 94-95,109*110
164, \h3f progression 56, )65-166 t>ody composition and 61
osteopenia 22. See also bone loss promotion strategies 174-175 bone cancer and 157
osteoporosis. Str bone loss proprioception 155 evidence of efficacy of 51,
ostomies 95,103 pnisUtiscaneer exercise prescriptions 59, 60, 89,
ototoxidty 22 body composition and 23,61 았_95
outcome evaluation 164,165/ car(norespirator)r fitness and 51 fatigue and 62
ovarian cancer 5,30 ^txerdse effects on 35-36,361, % head and neck cancer and 59-60
overload 56 exercise prescription for 51C 55, lymphedema and 59,63,104,157
overtraining 있, 105-106 , 햇2-95, ill quality of life and 62-63
overweight 30, 116, 122/, 123. Sfi fatigue and 62 suptrxision in 60
also obesity ht intake and 38 UlL DHHS guidctincs for 89,94-95
oxygen consumption 51,80t 61 infury risks and 93 resting blood pressure 75
obesity and 30 resting heart rate 75
P prevalence of 2f3f.4f.lO ivsting meUbolic rate (RMR) 125-126
paclitaxel 156 quality of life and 62 restrictive cardiomyopathy 21
pain 20,22-23 resistance training and 99,60 Revised European-American Clas
pancreatic cancer 30 screening for 5,61,7, 公>9 / sification of Lymphoid Neo
PARmed-X treatment for 8-9 plasms (REAL) 4
PAR-Q (Physical Activity Readiness pro&tate-speafic antigen (PSA) 5,7,9 role models 149
Questionnaire) 75,76f protein, dietary 127-12次 130,134/
peak oxvgen consumption 51,80t 81 pulmonary side effect* 21
p<、L_tri“urvi、(<s 22,24 safety
peripheral neuropathy Q early research based on 56
exercise prescription and 65•義6, quality conttol 169 eligibilih* criteria and client selec
104,156 quality of life 51161-63 tion S•於，831
symptoms of 2\, 65,156 Quctckt Indev See body mass index emergency procedures 157-158
from treatment 103,155,156 in exercise 96
treatment for 22 in exerdse testing 84-85
pesticide residues 129 radiation treatment facility quality control and 16公
phantom limb pain 21 for cancer types 7,8-9,11 feversand 154
physical activity. See exerdse cardiovascular changes from 21 food 130
The Physical Activity Guidflines for exerdse during 55,60 immune changes and 154-155
Americans (U.5. DHHS) 55, gaMrointrshnJI changes from 23 infecticMis and )54-155
88-90,^4-95 hypothyToidism after 22 injury risks 요3, %
physical activity profiles 83 immune function and 154 musoiloskeletal changes and 156-
Physical Activity Readiness Ques lymphatic system and 63 157
tionnaire (PAR*Q) 75,76( persistent changes from 19f salt intake 39
physicians schedules of 16 Sample Prescription Pad 〜75f
clearance from 75,91,97,98f skin and hair changes from 24 sarcoma, defined 2
medical releases, after emergencies timing of W-100 sarcopvnic obesity 123
158 range o, motion 60,101. Set also flex saturated fats 128
Presenting the Cancer Survivor to ibility exercise SCLC (small cell lung cancer) ^f, 10
the Physician form 168f-16^ rating of perceived exertion 157 screening. Ser cancer screening
186 Index
secondhand smoke 9 supervision^ in resistance exercise 60 weight management 122/

SEER (Surveillance, Epidemiology support groups 150 triple-negative breast cancer 16
and End Results》4 surgery 7,9-11,19t, 100-102. Set also TrM (transtheoretical model) 146-
self-efficacy 144*146,14私 148-149,150 treatment 147,14간 14회
sq>tic shock 154 Sun eillance, Epidemiologv and End tumors，biology of 2
sex slrroids 32 Results (SEER) 4 type of cxrtvise M
side ejects of treatment 16*24 survivorship care plans 18
cardiovascular 20-21,65 SVCS (superior vena cava syndrome)
U
co^nibvc impairment 2X104,14上 156 underweight
cachexia and 117,118,128
endocrine 22 in cancer patients 117-118,12b
fatigue 19-20,100,103,142 tamoxifen 8 classification of 122/，123
gastrointestinal 23 targeted therapies )0, IL 19| unilateral edema 157
immune function 23, bi, 99,102 taste Abnormalities 119 ' TJ.S. Department of Health and
long-term vs. late 1S-19 taxanes 103 Human Senices (U.S. DHHS)
musculoskeletal 22*23 temperature changes 67 exercise alterations for cancer sur-
neurological 21*22,65-66,1(田, 155, testicular cancer 22* 100 vivors 94-95
156 teakK•田one 9,67 physical activity guidelines of 55,
new client treatment form 17fA9f theory of planned behavior (TPB) 146 8^-90
organ function 23-24 Theory ot Quahty Management 165 on restsUnce training 59
pain 20,22-23 thc*mu>regulatofy symptoms 66*67 on standards for rehabilitation
persistent 1S-19,19f thrombopenia A6 centers 174
pulmonary 21 thyroid hinctinn 123 US. Food and Drug Administration
skin and hair 24 timing of exercise 54,55-56,60 (FDA) 133 J
sleep disturbance 20,142-143 tinnite 22 uterine cancer JO
we^ht charges 116,117-118 TNM classification system 3-4
6- or ]2*minute walk tests 51,80f, 81-^2 tooth loss 121
6* to 7-rrpetition maximum 59 tort law 173-174 vasumptor symptoms 66-67
skin cancer 24 total qualit)' management 165 vegetables 38,38f, 127,129
sleep, recording hours of 57f TPB (theon* of planned behavior) 146 verbal persuasion 145-146,145^ 149
sleep apnea trans fats 128 'vitamins 131*132,134f
sleep dysfunction 20,142-143^ transtheoretical model (TTM) 146- 하 vomiting, nutrition and 118
small cell lung cancer (SCLC) 4f. 10 147. 147* 148( W
smell abnormalities 11^ trastuzumab (Herceptin) 8,16,21, ^5
waist circumference 31-33,124,124f
social cognitive thvqry (SCT) 144- treadmill exerdsc tests 안*4 '
also obesity
146, U5f treatment. Set alsc side effects of
walking 54
social isolation, nutrition and 121 treatment
walk tests 51, 55,80t 81-82
soy products 130 adverse effect* 새H 0>105
aging from Utf 1Q2 water and hydrabon 131
spedhcity of training 56, S9,60
water retention 124
spinal cord compression 155-156 altemabve diet therapies 133
weight gain 61
squamous cell carcinoma 32 for bone k»ss 22
weight loss 117-118,125,126
stages of change model 146-147, bone ims from 67-68,131
weight management 117, 125*126,
Wf, 148( for breast cancer 7-8
12S. Set also obesity
staging system for cancer 3-5,4f, 5t complementaiy and alternative
weight status. Set body weight
stomach cancer 30,39 medicine 13z wholegrains 130
stomas 103 exercise during ps. after 50-51,
Women's Healthy Eating and Living
stomatitis 119 55-56 (WHEL) 126
strength training. See resistance exer hot flashes from 66-67
World Cancer Research Fund 114,
cise immune suppression and 23, 64,
115f
stress 126,14M44,150 99,102,154455
World Health Organization (WHO)
stress testing 80t, 81 infections and 154-155
4,20
submaximal exercise tests 79-82, )oint pain from 67
80t 公5 lympnedcnu from 63-64
sugar 37-38,127 neuropathy and 22,65-66 xerostomia 119
sun protection 100 new client treatment form 17^-1^
superior vena cava syndrome (SVCS) for pain 20
156 tuning of 99*100 yoga 20,61,95,143
About the Editor
Melinda L Irwin, PhD, MPH, is an associate
professor in the Yale School at Public Health
and codirector of the cancer prevention and
control research program at Yale Cancer
Center. Dr. Irwin’s research focuses on how
exercise and weight influence cancer risk
«nd survivoohip. Dr. Irwin b the principal
investigator of a number of research studies
at Yale University and collaborates on vari
ous national projects and initiatives focused
on exercise and cancer survivorship. She has
received funding from the National Cancer
Institute, American Cancer Society, Komen
for the Cure, Lance Armstrong Foundation,
and American Institute for Cancer Research
and has published her research findings in top
medical journals. Dr. Irwin also serves on vari
ous national advisory committees to devdop
consensus statements on physical activity,
diet, weight control, and cancer prevention
and control.
187
About the ACSM
Thr American College of Sports Medicine (ACSM》， academicians to students and from personal train
founded in 1954, is the world's largest sports medi ers to physicians, the association of 외x)rts medicine,
cine and exercise science organization with more exercise science, and health and fitness profession-
than 45,000 national, regional, and international ab is dedicated to helping people ^xirldwidc live
members and certified professionals in more than longer, healthier lives through science, education,
90 countries. With professionals representing more medicine, and policy. For more informatioa visit
than 70 iKcupations, ACSM offers a 360-degree www.acsm.org.
view of sports medicine and exercise science. From
189
other outstanding
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ACSM Guide To Exercise and Cancer Survivorship Final

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ACSM Guide To Exercise and Cancer Survivorship Final

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f 广） American College of Sports Medicine

American College of Sports Medicine

Melinda L. Irwin, PhD, MPH

Copy-righi C 2012 by American College of Sports Medicine

Printed m the United Slate* of America 10 9 6 5 4 3 2 I

United States: Human Kinetic*, P.O. Box 5076. dumpuign. IL 61825-5076

CHAPTER 1 Diagnosis and Treatment of Cancer............................... 1

Cancer Incidence and Survival.............................................. . .m ..f.......................... 2

CHAPTER 2 Side Effects and Persistent EflFects of Cancer Surgery

Side Effects of Cancer SurQery and T『的tment...................................... ............................ 16

CHAPTER 3 Lifestyle Factors Associated With Cancer Incidence,

Effect of Body Weight. ........................................... 30

CHAPTER 4 Benefits of Physical Activity After a Cancer

Physiologicai Effects of Exercise Training........................................................................... 50

Cancer-Specific Exercise Issues by Body System............................................................... 63

CHAPTER 5 Cardiorespiratory Fitness Testing in Clients

Administration of Cardiorespiratory Fitness .................................................. 74

CHAPTER 6 Exercise Prescription and Programming Adaptations:

Health Promotion and Risk of Disease Reduction..................... ....................................... 88

CHAPTER 7 Nutrition and Weight Management............................... 113

Diet in Cancer Prevention, Control, and Overall Health....................................................... 114

CHAPTER 8 Health Behavior Change Counseling.............................. 141

Effect of Cancer on Readiness to Exercise........................................................................ 142

Translating Theory Into Practice................................................. .................................... 147

CHAPTER 9 Safety, Injury Prevention,

CHAPTER 10 Program Administration...............................................161

Wendy Demark*Wahnefried, PhD, RD Tara Sanft MD

Lee W. Jones, PhD Anna L. Schwartz, PhD, FNP, FAAN

• General knowledge of the descnptive epidemiology of cancer, including the prevalence,

Cancer is an important cause of morbidity and mor­

Prostate 28% Breast

Lung and bronchus 1S% Lung and bronchus

Urinary bladder 7% Utenne corpus

Melanoma of skm 5% TtyraW

Non-Hodgkin lymphoma 4% Non-Hodglun lymphoma

Kidney and renal peMs 4% Melanoma of stun

Oral cavity 3% lOdney and _<_i pelvn

AN other tHM 19% Al otter sites

Lung and bronchus 29% Lung and bronchus

Prosiaie 11% B<«ast

Coion and rectum 오、 Cokm and reclutn

Uwr end mtrah«pattc Mt duct 4% Owy

Leukemia 4% NooHodgkm lymphoma

Urinary biacMer 3% Liver and mtrahepatic Me dud

TABLE 1.1 Summary of Ann Arbor Classification of Staging of Lymphoma

12 ACSMrs Guide to Exercise and Cancer Survivorship www.acstn.org

Cancer Recurrence modalities, and follow-up are important for pro­

Warni 매 Signs and survivors.

Signs of cancer recurrence are generally related to References

Summary cancer overview: Risk Uckm, scivening^ gunetK test­

Side Effects and

Side Effects of Cancer the fitness professional needs to understand the

Cancer type: Stage of diagnosis: 0 ■ II III IV

Date of diagnosis: Oncologist and date of last visit k

Date of surgery: Site of sumry: W

Impairments from surgery (if any):

2. Did you have chemotherapy? Vtes No

Date of completion: 오 Name of chemotherapy: - 〜T__________

Are you cunently receiving chemotherapy? Ybs No

Name of chemotherapy you are cunently receiving:

Do you have persistent side effects from chemotherapy? Yes No

Cancer is an important cause of morbidity and mor

Cancer Recurrence modalities, and follow-up are important for pro

Summary cancer overview: Risk Uckm, scivening^ gunetK test

Sleep Disturbance mediated by two pathways: nociceptive and neu

Renal Damage especially if the patient received multiple transfu

have UM*d a variety of aerobic exercise prescrip Frequency and Intensity

The 2010 ACSM roundtable guidelines for resis