QUESTION: WHAT IS THE PRIMARY TAKE-AWAY MESSAGE FOR ONCOLOGISTS?

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Exercise has concrete and significant benefits for adult patients with cancer who are undergoing systemic therapy or radiation and for patients with lung cancer in the perioperative period. Exercise reduces toxicities of cancer treatment, such as fatigue and decline in cardiorespiratory fitness, physical function, and strength. Exercise also improves quality of life and mood. Although there was insufficient evidence to determine whether exercise improves chemotherapy completion rates or dose intensity or reduces the risk of cancer recurrence or mortality, evidence clearly demonstrates that exercise helps to support patients undergoing cancer treatment. On the basis of this evidence, we believe that exercise should now become a routine part of the treatment of adults during active therapy.

QUESTION: WHAT SPECIFIC RECOMMENDATIONS CAN I GIVE MY PATIENTS?

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Aerobic and resistance exercise should be recommended for adult patients with cancer receiving active treatment, including chemotherapy and radiation. Exercise may also be recommended in the perioperative period for patients with lung cancer. The panel reviewed available evidence in an attempt to develop more specific guidance regarding the frequency, intensity, and duration of exercise, but ultimately concluded that available evidence did not provide sufficient granularity to develop specific exercise prescriptions of this type for patients in the active treatment period.

The panel also recognized that patients may need different kinds of programs to help them increase exercise. Although many patients undergoing cancer treatment will be able to exercise safely on their own, some patients will need supervised exercise programs or cancer rehabilitation to help overcome functional limitations because of treatment toxicity or comorbidities. National efforts are focusing on building algorithms and decision-support tools to point to the most safe, feasible, and effective intervention for a given patient.^6,7

QUESTION: WHAT IS NEEDED FOR EXERCISE TO BECOME A ROUTINE PART OF CANCER CARE?

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This guideline is an important first step in establishing exercise as the standard of care for patients receiving treatment for cancer. In addition, although studies have suggested that recommendations from oncology providers can help increase exercise behaviors, many patients will need longitudinal support to help foster long-term behavior change. Oncology providers will need training on how to provide exercise counseling and/or facilitate appropriate referrals to team members.⁸ Although many patients will be able to exercise on their own in their homes or in community-based settings, the creation of a network of clinical or supervised exercise programs will be needed for others, allowing clinicians to refer patients to programs that fit their needs. These programs will need to be offered at a variety of hours and reimbursed by insurers with minimal cost sharing to overcome patient barriers to participation and ensure that all patients have equal access to exercise as a part of their cancer care.

QUESTION: SINCE THE GUIDELINE DOES NOT PROVIDE RECOMMENDATIONS FOR EATING A HEALTHY DIET OR LOSING WEIGHT DURING TREATMENT, DOES THAT MEAN THAT THOSE THINGS ARE NOT IMPORTANT?

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The literature review for this guideline revealed a number of significant gaps in the evidence base. There were strikingly few studies that focused on the impact of a diet intervention—and almost none on a weight loss intervention—during treatment on any kind of outcome. In addition, in the trials that were available, there was considerable heterogeneity in the diets being tested and many studies were of low quality. This lack of evidence made it impossible to develop the same type of recommendation on the basis of data from RCTs for diet and weight loss during active cancer treatment that had been used to create the exercise recommendations.

The panel was quite conflicted on the best course of action given this lack of evidence. Observational data suggest that a plant-based diet and maintaining weight in a healthy range are associated with lower risk of cancer and better outcomes in some malignancies.² There are also many other health benefits of a plant-based diet and weight control on a myriad of health outcomes, including lower risk of cardiovascular and metabolic diseases, comorbidities prevalent in patients with cancer that contribute to inferior outcomes. A number of panel members felt that, in the absence of clear evidence regarding optimal diet or weight loss strategies during active cancer treatment, patients with cancer should be advised to follow guidelines developed to support general health. However, after vigorous debate and many iterations of the guideline, the absence of clear evidence supporting a particular diet or weight loss/maintenance strategy in patients currently receiving cancer treatment or in the perioperative period led the panel to conclude that there was not sufficient evidence to provide a specific recommendation. However, a note was added to the recommendations stressing that lack of research testing diet and weight interventions led to the inability to make specific guidance, rather than trials showing no effect, and that oncology providers should not be discouraged from speaking to their patients about diet and weight management on the basis of the guideline report.

There is significant interest in understanding the impact of diet and weight on cancer outcomes. Without high-quality evidence, patients may be at risk of pursing a diet that is unlikely to provide benefit—or may even be harmful. We hope that this guideline is seen as a call to action, highlighting the critical need for a significant investment in definitive research testing the impact of high-quality diets and prudent weight loss strategies on important outcomes such as treatment toxicity and cancer control in individuals undergoing cancer treatment.

QUESTION: WHAT SHOULD I TELL A PATIENT WHO IS INTERESTED IN PURSUING A KETOGENIC DIET, FASTING, OR OTHER POPULAR DIET DURING CHEMOTHERAPY?

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Many patients look to make changes in diet after cancer diagnosis. As discussed previously and described in detail in the guideline, there are few randomized trials testing specific dietary interventions during cancer treatment. Nutritional needs of patients during cancer treatment vary on the basis of the treatment regimen, nutritional status of the patient, and comorbidities. Some popular diets, such as ketogenic diets and fasting, could potentially limit nutrients that influence an individuals' ability to tolerate treatment and maintain functional status. Although some trials are ongoing, there are little safety data regarding the implementation of these types of dietary patterns in patients receiving cancer treatment. Patients who are interested in dietary change after cancer diagnosis could be counseled as to the lack of data supporting benefit of ketogenic diets, fasting, and other popular diets at this time.