Scientific evidences show that people living with and surviving cancer may practice physical activity with several benefits and without particular side effects if type, timing and intensity are targeted on their clinical status. Physical exercise may prevent or reduce cancer-related fatigue before, during and after therapy. This commentary would like to show that despite these evidences, less is still known about effectiveness of physical exercises programs since hospitalization. Therefore, reporting an Italian example of multidisciplinary model of rehabilitation and educational program, started during hospitalization in Oncology ward and continued at discharge, we would like to underline the importance, to promote a safe life styles to increase the quality of life and not only the amount of cancer patients.
breast cancer patients, cancer-related fatigue, colon-rectus cancer Patients, hospitalization, physical exercise, rehabilitation
As reported by the EUROCARE-5 study, survival for patients with cancer increased from 1999-2001 to 2005-2007 despite some differences across Europe with lowest survival observed in Eastern Europe [1-3]. In Italy, an increasing survival of about 20% is registered after cancer diagnosis in the last years , on the basis of the information from the Italian Association of Cancer Registries (AIRTUM)  database [6,7]. Despite of the increasing survival, about 4,9% of the Italian population has a cancer diagnosis and on 365.800 new diagnoses in 2016, the breast and the colon localizations are the most frequent, with 52.000 new diagnoses for the colon-rectus cancer and 50.000 new diagnoses for breast cancer . In this scenario, cancer networks and multidisciplinary approach may play a key role , including rehabilitation and physical exercises programs for people living with and surviving cancer . The goal, today, is to increase the quality of life and not only the amount of this in cancer patients .
We know that disability, cardiovascular disease risk, morbidity, and mortality are influenced by several physical benefits of exercise, including peak oxygen consumption, functional capacity, muscle strength and lean mass, cardiovascular risk factors, and bone health. There are many evidences that physical activity have a positive impact on physiology, body composition, physical functions, psychological outcomes, and quality of life in cancer patients during therapy [11-14], after completion of cancer-related main treatment [15,16], after and during adjuvant treatment  and to reduce long-term side effects , especially in breast cancer  and colorectal cancer patients . Those benefits are not dependent on cancer type, in particular cardiorespiratory and fatigue improvements following rehabilitative exercise .
Exercise therapy is effective for decreasing pain in patients during and following cancer treatment [22,23], and to improve quality of life during active treatment and for survivors [11,13,14].
Physical exercise may prevent or reduce cancer-related fatigue (CRF) before, during and after therapy [24-27], but less is known about effectiveness of physical exercises programs for CRF in advanced cancer patients . Exercise during cancer therapy probably results in less fatigue and improved physical fitness and resistance exercises programs appeared to contribute to maintain quality of life. Both aerobic and resistance exercises can be regarded as beneficial for patients with therapy-related side effects. For those reasons clinicians should prescribe exercise, eventually in associations with psychological interventions, as first-line treatments for CRF . Nevertheless, further research is required to determine the optimal type, intensity, and timing of an exercise intervention [30-32].
The existing reviews and guidelines on physical activity and rehabilitation are generics, the target is to avoid inactivity, some benefits are evident for regular sessions and for moderate intensity exercise , an additional benefit of multi-dimensional over mono-dimensional rehabilitation was not clearly found, home-based programs are also effective and nevertheless a favourable cost-effectiveness is shown. Further research is needed to develop more personalized programs that should take into consideration interests and preferences of patients to facilitate optimal interventions [23,34-40].
Although it is known in the literature, as stated earlier, that people living with and surviving cancer may practice physical activity with several benefits and without particular side effects if type, timing and intensity are targeted on their clinical status. However, many patients are inactive and do not meet exercise recommendations. Clinicians should promote exercise since hospitalization, discussing with patients the benefits of physical activity and implementing educational programs to bridge the gap between research and practice [37,41-43].
On that basis, the Rehabilitation Service of Parma University-Hospital, in collaboration with the Clinical Oncology Unit, is proposing a model of rehabilitation and promotion of life styles for cancer patients starting from hospitalization in Oncology ward. It is an inpatients rehabilitation project based on an aerobic and resistance exercises program supervised by a physical therapist specialized in oncological rehabilitation and dedicated to this activity. The goal of the intervention is to promote an educational program of good life style in cancer patients by explaining the benefits of physical activity and by training the patients and the caregiver to perform the exercises correctly. At the discharge a personalized home-based exercise program is explained and described to patient and caregivers, according to the one performed during hospitalization.
The rehabilitation and promotion of life styles program is conducted according to international standards of good practice, such as the Declaration of Helsinki and Good Clinical Practice.
A physical and rehabilitation specialist selected patients from Clinical Oncology ward of Parma University Hospital, with different type of cancer and in different phases of treatment, aged between 18 and 70 years, without clinical complications that could interfere with physical activity (e.g. sepsis, fever, immunocompromised patients) or apparent cognitive impairment, with a recovery time of at least 5 days. Patients before starting the rehabilitation program had to accept to participate at an informational interview and completion of informed consent
During the first 2 months of program, 65 patients were hospitalized in Clinical Oncology ward. 43.08% were male (n=28) and the 56.92% were female (n=37), 28 patients did not meet inclusion criteria, 14 (the 38%) refused to participate to the program. Twenty-three patients were recruited for the study, but 12 dropped out because of clinical complications. Only 11 patients completed the program during two months of recruitment (7 male: mean age 64 ± 11.5 SD years; 4 female: mean age 69 ± 5.8 SD years).
After history taking and first physical examination, patients were divided into 2 groups according to the disability: in group A were allocated patients able to walk, in group B patients that for different clinical conditions were not able to walk.
Both groups were evaluated at admission with the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) version 3.0 questionnaire to assess quality of life [44,45], Mini Mental State Examination (MMSE) to assess cognitive functioning , Modified Barthel Index (BIM) to assess independence and disability , Karnofsky Performance Status scale (KPS) to quantify the functional status , handgrip strength was assessed with Jamar dynamometer  and Numering Rating Scale (NRS) for pain and fatigue. Two-minute walking test (2MWT) [50,51] and Short Physical Performance Battery (SPPB) to test physical performance and balance [52,53] were used only for group A and Trunk Control Test (TCT) only for group B . At discharge patients were assessed with a specific satisfaction questionnaire concerning rehabilitation treatment received and BIM, KPS, NRS, handgrip test. SPPB, 2MWT and TCT were assessed depending on group.
The 5-session exercises program was initiated the day after the first physical examination and baseline evaluation, according with clinical conditions of the patients. Sessions lasting approximatively 45 to 60 minutes, depending on patient ability and on group and occurred every day. Vital signs were assessed before and after each session, at the end of the session even NRS for pain and fatigue and presence of dyspnoea were assessed. Participants were allowed to make up sessions missed due to clinical complications as long as the entire exercise program was completed. During a 10-minute warm-up period, patients performed range of motion and stretching exercises for the trunk and lower and upper limbs. Participants then completed 15 minutes of aerobic exercise on an arm bike. For the strength training part of this exercises program, patients performed 3 sets of 10 repetitions of 6 different exercises (e.g. 3 lower extremity and 3 upper extremity movements), for a total of approximatively 20 to 30 minutes, exercises were modified or discontinued for patients that were unable to complete them. A cool down period of 1 minute followed every repetition. Then only participants of group A completed another 15 minutes of aerobic exercise session with walk at middle speed on a flat, straight and hard surface path. A cool down period of 2 to 5 minutes followed the aerobic session on both, the bike and the walk.
At discharge, it is expected that a restricted group of patients with breast or colon cancer after adjuvant treatment, in good clinical conditions, will be trained for a personalized exercises program in a professional gym. They will be evaluated by a Sport Medicine Specialist for the best physical performance for achieving the goal level of intensity for the aerobic exercise (heart rate between 70 and 85% of their maximum) and the strength of major muscle groups associated with performing activities of daily living (the maximal amount of weight that each muscle group can move through the available range of motion). On the basis of those evaluations they will be trained by specialized personnel for a personalized exercises program of 12-session, each lasting approximately 60 minutes, occurred twice weekly over the course of 1 month. After this training, patients should continue their physical activity in a gym or with an home-based program. This will be a rehabilitation clinical model based on physical exercise that start in the hospital and continues for outpatients to support survivors in prevention of recurrences and managing of cancer-related long term complications.
For all participants (inpatients and outpatients) a follow-up at 6 months with EORTC QLQ-C30 is expected, to assess quality of life after discharge and to notice if patients are attending their physical activity with home-based program or in a gym.
To assess variation in the collected information between admission, discharge and a 6 month Follow-up, an Anova Repeated Measure will be performed.
Nowadays no patients have completed the entire program. The small sample investigated (n=11) during the 2 months of recruitment does not allow to statistically demonstrate the effectiveness of the structured exercises and promotion of life styles program for cancer patients. However, some improvements in physical performance for both group A and group B patients were observed.
The group A data reported an improvements in the distance in meters performed during 2MWT and in the energy produced during arm bike session between admission and discharge. Furthermore an improvement of fatigue has been observed. Group B has shown an improvement in number of repetitions for the strength training part of this exercise program, an improvement of pain, fatigue and of SPPB.
The survey relatively to usefulness and satisfaction to the treatment, has allowed us to detect a positive judgment, to support the model of inpatients treatment proposed.
The aim of the Italian experience is to evaluate the effectiveness of a brief program of inpatients rehabilitation and promotion of life styles (at least 5 days) in the Oncology ward of Parma University Hospital. Preliminary data observed represented a positive trend for both the participants’ performance and satisfaction concerning the treatment proposed.
As stated earlier, the small sample investigated (n=11) during the 2 months of recruitment does not allow to statistically demonstrating the effectiveness of the structured exercises and promotion of life styles program for cancer patients. Nevertheless this experience is different from those reported in the literature, in our knowledge, for the presence of a therapeutic program for an inpatient limited in time. Furthermore we have proposed a structured, reproducible and easy exercises protocol that according to current clinical and scientific recommendation could be compared with other experiences.
Considering the degree of comorbid disease and health status of inpatients in the Oncology ward of Parma University Hospital, we supposed an adherence rate of 70% to be an acceptable goal. Our target during the 2-year study period is approximately 100 patients. It will be necessary to continue the study to evaluate the efficacy of the model proposed in the short term with the inpatients assessment. In medium and long term the effectiveness of our rehabilitation model will be evaluated with follow-up and with the observation of the personalized exercises program in the professional gym for a restricted group of patients with breast and colon cancer after adjuvant treatment.
Evidences shown that physical activity have a positive impact on physical functions, psychological outcomes, and quality of life for patients living with and surviving cancer [11-18] especially in breast cancer  and colorectal cancer survivors .
If the results of this study are positive it will be possible to implement current local clinical practice for cancer patients, by providing a rehabilitation and clinical care pathway based on physical exercise starting during hospitalization and continuing outpatients after adjuvant treatment. This model of rehabilitation is in accordance whit the Evidence Based Medicine and Practice.
We are grateful to all the multidisciplinary team of Parma who worked to produce the on-going rehabilitation program and to all patients that accepted to participate. Special thanks are due to Dr. Alberto Anedda, Director of the Sport Medicine Unit, NHS Local Agency of Parma, Italy, for having contributed to continue, for the first time in Parma, a physical exercise program of the cancer patients, also after discharge.
The Parma experience is a No Profit Research. However we have to be grateful to the not-for-profit association A.VO.PRO.RI.T. (Associazione Volontaria Promozione Ricerca Tumori), for Financial support.
1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data: FR, FeP, VS, CC, VF, FaP, RB
2) drafting the article or revising it critically for important intellectual content: FR, FeP, VS, CC, VF, FaP, RB
3) final approval of the version to be published: FR, FeP, VS, CC, VF, FaP, RB
4) agreement to act as guarantor of the work (ensuring that questions related to any part of the work are appropriately investigated and resolved): FR, FeP, VS, CC, VF, FaP, RB
The authors declare that they have no competing interests
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