Defining Characteristics of Exercise and Rehabilitation Stepped Care Services
Using a stepped care framework from the highest intensity care to the lowest, rehabilitation and exercise services recommended for cancer survivors include: cancer rehabilitation; clinically supervised exercise; supervised, cancer-specific community-based exercise; and unsupervised, or generic, community-based exercise [8, 10]. Characteristics that differentiate each level of stepped care are summarized in Table 1, including: level of care as described previously by Alfano & colleagues [8]; minimum requirements of delivery personnel; facility characteristics; focus of service; short and long term goals of service; cost and functioning considerations; caveats; and general patient qualifiers synthesized during our literature review.
Conceptual model of the multidimensional factors that influence stepped care needs
Figure 1 depicts how the ability of an individual with cancer to transcend the levels of stepped care services (part b) is a function of multidimensional factors (part a), described previously by the International Classification of Function, Disability and Health [9] and the work of Alfano & Pergolotti [11]. Throughout the cancer care continuum these factors interact to increase or decrease risk of exercise-related adverse events and need for specialized care. Thus, Figure 1 is designed to represent the multitude of factors that can influence stepped care need at any cross section of time along the cancer continuum. Accordingly, the EXCEEDS algorithm is designed to be used at any time to guide triage decision making based on an individual’s risk of exercise-related adverse events and need for specialized care.
The EXCEEDS preliminary algorithm
The EXCEEDS preliminary algorithm is a two-part tool designed to identify exercise-related risk and provide appropriate triage recommendations. In the EXCEEDS algorithm, risk-stratified branching logic is used in each section and domain to minimize the amount of information necessary to make medical clearance and triage recommendations. See Figure 2 for the EXCEEDS algorithm flow chart. Patients should be re-evaluated at each stage of the cancer care continuum [12] as part of prospective surveillance [13, 14] and in the presence of any adverse event, change in health status, or exercise motivation.
Section 1 of the algorithm includes three domains (Physical Activity Level, Presence of Chronic Disease, and Medical Follow-Up questions) that determine need, or no need, for pre-participation medical clearance. Pre-exercise medical clearance is only indicated for individuals who are not sufficiently active (i.e., <30 minutes moderate intensity exercise, 3x per week for 3 months [15]) and have a positive (“yes”) response to at least one question in the chronic disease or medical follow-up domains. Section 2 includes seven domains: cancer-specific factors, functional factors (level 1 & 2), side effects (level 1 & 2), presence of catheter, and exercise self-efficacy. Stop logic is used in each domain so that a recommendation can be provided immediately when risk/specialized care need is identified. For example, if a positive (“yes”) response is provided for any question in the cancer-specific factors domain, referral to cancer rehabilitation will be immediately recommended and no additional questions will be prompted. See Table 2 for additional detail on the criteria and references for each domain.
Justification of Triage Recommendations for Each Level of Stepped Care
Cancer Rehabilitation
Cancer rehabilitation services are delivered by licensed healthcare professionals with expertise in therapeutic interventions to maintain or restore function, reduce symptom burden, improve quality of life, and maximize independence by improving a patient’s ability to participate fully in work, leisure, and other life roles [8, 11]. Randomized trials and practice-based evidence have demonstrated many of these benefits throughout the cancer care continuum, including enhanced physical health or functioning [16, 17], reduced symptom burden [17], enhanced quality of life and participation [17–20]. Physical and occupational therapists (PT/OT) are the primary recipients of triage recommendations from the EXCEEDS algorithm due to the exercise-related nature of the tool and PT/OT services; however, additional members of the cancer rehabilitation team are noted in Table 1 because many patients will have needs outside the PT/OT scope of practice. Using the EXCEEDS algorithm triage to cancer rehabilitation is recommended for individuals who have at least one cancer-specific factor, level 2 functional factor, or level 2 side effect.
Clinically Supervised Exercise Services
Clinically supervised services may be a pragmatic and accessible supplement to cancer rehabilitation for some individuals with comorbidities (e.g., patient with cardiac instability but no other functional limitations) or those with limited accessibility to rehabilitation for geographic or financial reasons (i.e., no local cancer-specific rehabilitation clinicians; no or limited insurance, high out-of-pocket costs). Intervention is typically led by an exercise clinician with oversight from a rehabilitation or other clinical specialist including nursing. Although the effectiveness of these programs has not been reviewed exclusively, many studies have demonstrated positive effects and impacts for cancer survivors, including improved fatigue [21–23], function [21, 22, 24, 25], quality of life [22], symptom management [25], fitness [22], physical activity level [23], and health-care utilization [25]. However, we recommend a minimum requirement of an evaluation by a qualified cancer rehabilitation practitioner prior to initiating such exercise programs to ensure the patient’s safety and maximum benefit. Clinically supervised exercise is the minimum level of care recommended for individuals who are currently inactive and have at least one response in the chronic disease or medical follow-up domains. Using Section 2 of the EXCEEDS algorithm, we recommend triage to clinically supervised exercise for individuals with at least one level 1 functional factor or level 1 side effect.
Supervised, Cancer-Specific Community-based Exercise
Many cancer-specific and supervised programs exist across the US (see Table 1), and the ACSM has recently led efforts to consolidate information about these programs into a publicly available database directed toward clinician and individual use. The reach, effectiveness, implementation, impact (on quality of life) and maintenance of cancer-specific community-based programs have been recently summarized [26]. In general, they have been determined to be safe and effective to improve quality of life [26, 27] and physical function [28]. Many individual programs have demonstrated improvements on cancer-specific outcomes [29, 30] and long-term sustainability [23, 31–34], including the Livestrong® at the YMCA program [32], which was available in 791 YMCAs across the US (as of April 2020).[1] Supervised, cancer-specific community-based exercise is the minimum level of care recommended for individuals who are currently active and have at least one positive response in the medical follow-up domain. Using section 2 of the EXCEEDS algorithm, we recommend that individuals who have a catheter (due to NCCN guidelines [35]) and/or low exercise self-efficacy[2] be triaged to supervised, cancer-specific community-based exercise interventions.
Unsupervised or Generic, Community-Based Exercise
Unsupervised community-based exercise includes self-directed exercise in any setting, often community- or home-based. For the purposes of this article we include generic (i.e., non-cancer specific) community-based services with this category due to lack of cancer-specific supervision. Generic exercise includes traditional fitness classes, SilverSneakers®, worksite wellness, and personal training with a non-specialized trainer. Due to the evidence that supervised exercise is superior to unsupervised exercise for cancer survivors [36], we have based triage recommendations on a survivor’s level of exercise self-efficacy. Although home-based exercise is often preferred by individuals living beyond a diagnosis of cancer [37–39], research has demonstrated only mixed effects on function, cancer-specific outcomes, and quality of life [28, 40, 41]. Therefore, recommendations for home-based exercise should be made with caution, based on the needs of the patient, and accompanied by personal support and local resources. Using the EXCEEDS algorithm, only survivors with all negative responses and high exercise self-efficacy will be recommended to start/continue independent or generic community-based exercise exclusively. At the discretion of the appropriate rehabilitation or exercise professional, survivors may be encouraged to participate in independent or generic community-based exercise as a complement to specialized services.