Core Issue 3: Physical Exercise ▲ He Yi Wang Yan, Department of Rehabilitation, Peking University Cancer Hospital Randomized trials have shown that physical exercise is safe and effective for cancer survivors. Aerobic fitness and endurance training can improve cardiovascular function and have a positive effect on quality of life, as has been demonstrated in several studies of breast cancer patients. Tang Ligong, Department of General Surgery, Henan Cancer Hospital In addition, physical exercise is associated with decreased cancer incidence and recurrence rates and increased survival rates. Data from colorectal cancer, ovarian cancer, non-small cell lung cancer, brain tumors, and prostate cancer have all shown that physical exercise is associated with decreased mortality. Therefore, a physical activity section has been included in the Survival Guide. The guidelines encourage all patients to participate in physical activity as much as possible and recommend individualized physical activity based on survivor ability. The guidelines recommend a general physical activity intensity for cancer survivors of at least 150 min of moderate-intensity activity or 75 min of high-intensity activity per week, and strength training and muscle stretching two to three times per week. Overall assessment First, ask the cancer survivor what type of exercise he or she has done previously and what he or she is currently doing to assess his or her physical activity level on a regular basis. Second, a clinical assessment is performed, including vital signs, systematic review, disease status, and possible impediments to physical exercise, the latter commonly due to lack of time for exercise, lack of suitable exercise sites, lack of knowledge about exercise, and presence of physical impairment. Symptoms such as pain, fatigue, and psychological distress should also be assessed, as improvement in these symptoms can help with physical activity. Finally, comorbidities of cancer survivors, including cardiovascular disease, lung disease, arthritis, lymphedema, peripheral neuropathy, and fall risk, should be assessed to determine the level of risk of adverse events resulting from exercise. Risk assessment The level of risk for physical exercise is related to tumor staging, treatment modality, and severity of comorbidities, which are classified as high, moderate, low, and contraindicated by the Survival Guide. ☆ Low-risk patients are mainly cancer survivors in the early stages with high baseline levels of physical activity and no comorbidities, who can perform general physical exercise. ☆ Moderate risk patients include cancer survivors with peripheral neuropathy, bone metastases, and arthritis, who can perform general physical exercise and can be considered under the guidance of a professional. For those with peripheral neuropathy, stability and gait should be assessed; for those with osteoporosis or bone metastases, fracture risk should be assessed. ☆ Patients at high risk, including those with a history of pulmonary/large abdominal surgery, stoma, cardiopulmonary comorbidities (e.g., COPD, coronary artery disease), lymphedema, and severe fatigue, must exercise under professional supervision and should start with low-intensity exercise and slowly increase the amount as tolerated. Aerobic exercise and exercise on the non-affected limb can be performed with lymphedema, and strength training is safe and may improve edema symptoms. The “Survival Guide” specifically lists precautions for strength exercise in people with lymphedema and specifies that there is a high risk of exercise on the affected limb. ☆ Contraindications to physical exercise include patients who have had surgery for less than 30 d, severe anemia, and worsening disease. The American Cancer Society and the American College of Sports Medicine give specific recommendations for physical exercise for cancer survivors: ☆ Encourage all cancer patients to participate in physical exercise and resume daily activities as soon as possible. ☆ Physical exercise should be individualized according to the cancer survivor’s ability and willingness. ☆ General recommendations for cancer survivors: perform at least 150 min of moderate-intensity activity or 75 min of vigorous-intensity activity, or both, in equal amounts each week; perform strength exercises, including large muscle groups, in 2-3 week cycles; and stretch major muscle groups and tendons for other exercises. “The Survival Guide expert panel supports these recommendations, but notes that: ☆ It is recommended that survivors with low activity levels start with light or moderate intensity physical exercise for 20 min, 1-3 times per week, and gradually build up; starting with high intensity, high frequency exercise is not recommended. ☆ Encourage a variety of exercise modalities or increase the duration of physical activity; walking and stationary cycling are safe for all cancer survivors. Some studies have looked at patient preferences for exercise to identify strategies to effectively motivate patients to increase exercise, but no studies have yet shown which type of exercise is best. “The Survivorship Guide recommends strategies to help survivors increase physical activity and includes recommendations from sports scientists and/or practicing physical activity scientists. The data show that some oncologists give overloaded exercise recommendations, and some do not even discuss healthy behaviors with cancer survivors. There are benefits to participants participating in a monitored physical activity program/class or using a pedometer for exercise, and distribution of informational materials and telephone counseling are effective in increasing physical activity in patients. Core Issue 4: Fatigue ▲ Zhang Hongyan, Department of Oncology, Beijing Military General Hospital NCCN defines cancer-related fatigue as a persistent subjective feeling of fatigue that is associated with cancer or cancer treatment and interferes with normal life. It has been reported that 17-26% of cancer survivors experience persistent fatigue. Compared to survivors without fatigue, fatigue interferes with patients’ participation in meaningful activities and is more likely to result in depression. “The Survival Guide describes the methods, assessment process, and interventions for assessing fatigue. Screening and assessment The following questions are asked before assessing fatigue (Figure 1). A “yes” answer to question 1 or 2, or a score of ≥4 on question 3, is required for assessment of fatigue. Weakness as a vital sign should be assessed by periodic screening as follows: How would you rate your level of weakness over the last 1 week on a scale of 1 to 10, with 0 being no weakness and 10 being the most severe weakness you can imagine? ☆ No malaise to mild malaise (0~3 points): No treatment, regular assessment. ☆ Moderate weakness (4~6 points) or severe weakness (7~10 points): Detailed clinical examination and evaluation are required. Identify the causative factors Address the influencing factors If the cause of weakness is to be identified, a detailed history, physical examination, laboratory and imaging tests are required. Firstly, recurrence of cancer metastasis should be excluded, then whether it is related to tumor treatment should be clarified, followed by addressing the associated factors that may cause or promote weakness. History inquiry and physical examination (1) History of malaise: Carefully inquire about the time of onset, pattern and duration of malaise, changes over time, correlated factors or remitting factors, and impact on function. (2) Disease assessment: assess the risk of tumor recurrence or metastasis based on disease stage, pathologic factors, and treatment history, and fully analyze possible symptomatic support for suspected patients. (3) Evaluation of factors that can intervene to promote weakness: focus on possible complications, ask about the presence of alcohol or drug abuse; the presence of abnormalities in vital organ (respiratory, circulatory, endocrine, etc.) function; anemia; and arthritis. Ask about medication history, such as any ongoing use of sleep aids, painkillers, or antiemetics. Assess for psychological disorders – screen for anxiety and depression. Assess for sleep disorders, such as insomnia, sleep apnea, vasodystrophy, restless legs syndrome. Evaluate for pain. For nutritional issues, focus on weight changes or changes in caloric intake and dysfunction. Laboratory evaluation (1) Consider laboratory tests based on the presence of symptoms, time of onset and severity of malaise; (2) complete blood count and classification; (3) comprehensive evaluation of metabolic status, including electrolytes and liver and renal function; (4) endocrine evaluation, testing for thyroid stimulating hormone or consulting with the appropriate specialist based on other symptoms. Imaging (1) Consider imaging for those at high risk of disease recurrence or with accompanying signs and symptoms suggestive of metastatic disease. (2) Consider echocardiography or cardiac radionuclide scan for those receiving anthracycline antibiotics, trastuzumab, bevacizumab, or other VEGF/HER-2 targeted therapies. (3) Consider chest x-ray and oxygen saturation testing for those with pulmonary symptoms. Once the cause of malaise is identified, treatment of factors that promote malaise, including adverse reactions to medication, pain, psychological disorders, anemia, sleep disorders, nutritional deficiencies/imbalances, and complications, should be addressed first. It is important to note that further evaluation is considered for those with persistent anemia or erythrocytopenia. Interventions Patient/family education and counseling include status during and after treatment, self-monitoring of fatigue levels, and preservation of physical fitness. Physical activity Maintain appropriate levels of physical activity, local resources may be utilized to help patients increase exercise, such as fitness classes at cancer centers, community events focused on cancer survivors, professional fitness activities certified by sports medicine specialties, etc. Physical therapy may be considered if the patient has severe weakness that affects physical function. Other behavioral interventions Interventions should be culturally specific and adapted to the needs of the patient and family based on the disease process. The reason for this is that not all patients will accept or receive these recommendations, as individual circumstances and resources are different. The main components include psychosocial interventions, cognitive-behavioral therapy/behavior therapy, psycho-educational therapy/educational therapy, and supportive-expressive therapy; nutritional counseling; and sleep-specific cognitive-behavioral therapy. Medication After other causes of fatigue have been removed and other interventions have failed, central stimulants (methylphenidate or modafinil) or nutritional supplements may be considered. The “Survival Guide” emphasizes the need to first identify the cause of fatigue, and secondly, to treat the factors affecting fatigue, including pain, anxiety, anemia, and sleep disturbances. Notably, behavioral interventions at the psychosocial level are all Type I evidence, and there is more evidence to support the ability of physical activity to improve malaise. This suggests that psychological factors are the main cause of malaise after excluding the disease itself, therapeutic causes, and functional causes of organs. In contrast, appropriate physical activity is significant for the improvement of weakness. However, further research is needed to clarify the mode, intensity, interval and duration of physical activity. When none of the above interventions are effective, central stimulant drugs can be tried, although the use of such drugs needs further research.