Virtual Exercise Programs May Help Cancer Patients

Key Points

• Most study participants (67.3%) said the intensity of the virtual exercise regimen was similar to that of an in-person program.
• Participants reported no adverse events related to virtual exercise training.
• Physical and psychological outcomes improved significantly during the 12-week intervention.

Exercise as a Cancer Drug

Exercise is now known to be as effective as medication for cancer patients (see our article “Sport and Exercise May Shrink Tumors”). However, social distancing during the COVID-19 Pandemic forced doctors and cancer patients to adapt in various ways. A new study investigated the feasibility, effectiveness and acceptability of remote/virtual exercise programs. Findings published in Current Sports Medicine Reports show physical and psychological benefits, and the authors conclude that remote intervention is a suitable option during in-person exercise training.

Online Exercise Coaching

Researchers evaluated 491 patients receiving cancer treatment at Kettering Medical Center in Dayton, Ohio, between March and June 2020, who were enrolled in a cancer exercise program provided free through the nonprofit Maple Tree Cancer Alliance for cancer patients and people without a cancer diagnosis.

Of the 491 patients, 423 had enrolled in Maple Tree Cancer Alliance before COVID-19-related social distancing began. The rest started the program virtually in March 2020. Ages ranged from 14 to 83, with a median of 60. Eighty-four percent were women; 74.7% were White, 10.2% African American, 3.9% Hispanic and 5.7% Asian. The ethnicity of the remainder was unknown. Most had breast (58.2%), colon (4.5%), prostate (2%) or lung cancer (3.9%).

After asking whether each participant had fitness equipment at home, researchers developed a virtual assessment of each patient's fitness. They then created a personalized exercise program focused on individual patient goals.

At the initial visit, patients provided demographic information (such as age, sex and education) and their medical history. They also completed a 35-item symptom checklist to assess possible cancer-treatment side effects. It included physiological items such as pain, cough and dizziness, as well as emotional symptoms such as well-being and sadness; participants rated each symptom from 0 (absent) to 10 (very severe). They then met individually with an exercise oncology trainer virtually. Each patient completed 12 weeks of prescribed, individualized exercise.

The aim was for participants to complete 150 minutes of cardiovascular training per week in sessions lasting approximately 30 minutes; full-body strength training involving all major muscle groups (using free weights, elastic tubing and/or body-weight exercises, depending on availability); and flexibility training (static stretching). The trainer met virtually with patients once a week but assigned homework to keep them actively exercising at least 3 days a week.

Because patients spent different amounts of time in in-person and virtual training, researchers analyzed the percentage change in each physical and psychological outcome for all participants combined and separately for 4 groups:

• In-person, virtual to in-person.
• In-person, virtual to virtual.
• Virtual to in-person.
• Virtual to virtual.

Study Results

Participants completed 4949 of 5892 prescribed, supervised exercise sessions, with adherence rates of 84% for virtual sessions and 89% for in-person sessions.

18 participants (3.5%) left the program before completion, almost all citing health and family issues. None of the participants reported any adverse event related to virtual training. Senior study author Kathryn Schmitz, a distinguished professor in the Department of Public Health Sciences, Kathryn Schmitz, said, "With more than 1000 total sessions completed by approximately 500 patients, no injuries were reported and there were no adverse effects", adding: “This is very important because doctors often delay/stop referring patients to this program out of concern about adverse events.”

Overall, patients experienced improvements in:

• Cardiovascular endurance (15.2%, P < 0.05).
• Muscular endurance (18.2%, P < 0.05).
• Flexibility (31.9%, P < 0.05).
• Sense of support (58.7%, P < 0.05).
• Quality of life (32.2%, P < 0.05).

There were also decreases in:

• Feelings of loneliness (54%, P < 0.05).
• Fatigue (48.7%, P < 0.05).

Patients who completed a timed “Get Up and Go” assessment (an alternative to a treadmill test for people at risk of falling) improved their time to walk approximately 3 meters by 27.5%. There were no significant differences in completion rates among the 4 groups with different combinations of in-person and virtual exercise supervision.

Most participants (67.3%) said the intensity of the virtual exercise program was similar to the in-person program; 12.3% found it harder, while the rest (21.4%) found it easier.

Implications of the Study

Given everything we know about the benefits of exercise, particularly for cancer patients, we need to be creative in overcoming new barriers to exercising. This study provides strong evidence for adapting a highly personalized exercise program virtually at a time when in-person solutions are not always safe or feasible.

There may be other research and clinical scenarios in which individualized virtual training is appropriate and beneficial. One obvious example is its use among patients unable to meet at a central location, particularly those living in rural areas or with limited transportation options.

When delivered by well-trained staff, virtual exercise oncology programs appear appropriate, safe and effective in improving fitness, function and symptoms. This matters because at every appointment, doctors decide whether to continue the same chemotherapy dose based on patients' function and symptoms. Exercise is a powerful medicine and should be considered part of standard care for cancer patients.

In conclusion, just as we do not abandon cancer treatment and switch to another treatment when one does not work for a patient, we should seek other ways to exercise when certain programs are not feasible.