Too much, too little, or just right: Exercise triage pathways for patients with cancer

The integration of exercise into oncology care is widely recognized as a crucial component for mitigating treatment-related side effects, enhancing patient-reported outcomes and quality of life, and possibly even improving cancer outcomes.^{1, 2} However, despite strong recommendations from the American Society of Clinical Oncology³ and the American College of Sports Medicine,⁴ the incorporation of exercise into the care of patients with cancer remains inconsistent across oncology care settings, and many patients with cancer do not engage in regular exercise. A nationally representative study of US cancer survivors indicated that, in 2018, only 47% of patients engaged in recommended levels of aerobic physical activity, 24% participated in recommended muscle-strengthening activities, and only 18% met both recommendations.⁵

A major barrier to the incorporation of exercise into oncology care is the absence of a standardized triage system that systematically assesses and refers patients to appropriate exercise and rehabilitation services. A 2020 American Society of Clinical Oncology survey of 2419 patients with cancer indicated that, although 56.8% reported discussing exercise with their oncology providers, only 14.7% received any kind of referral to an exercise program.⁶ Notably, the needs of patients who have cancer vary significantly based on treatment phase, physical function, and comorbidities. Connecting patients to appropriate exercise support requires initial screening of baseline exercise behaviors as well as functional impairments related to cancer, treatment, and underlying comorbidities. These factors inform triage and referral to the appropriate level of support to increase or maintain exercise. Notably, successfully supporting the large number of patients with cancer who could benefit from exercise as a part of their treatment would require the incorporation of this screening, triage, and referral process into clinical care as well as the availability of affordable exercise and rehabilitation programs to which patients could be referred.

In this issue of Cancer, Simon and colleagues present their work investigating the feasibility and acceptability of a model designed to integrate an exercise triage and referral system in cancer clinics—the Comprehensive Oncology Rehabilitation and Exercise (CORE) clinical workflow algorithm—in patients with newly diagnosed breast cancer undergoing surgery.⁷ Study participants were randomized 2:1 to the CORE clinical workflow algorithm or to standard surgical care. Patients randomized to CORE underwent assessment of exercise behavior and physical function by completing a brief survey as part of the check-in process for their initial surgical consultation and their postoperative visit. The assessment was used to assign patients to one of three levels of exercise support: rehabilitation services, a supervised exercise program provided free to patients at the cancer center, or unsupervised exercise. Of the 47 participants who were assigned to CORE, the majority completed the CORE screening assessment at the presurgery (92.5%) and postsurgery (94.6%) time points. In addition, at the presurgery time point, 18 of 29 patients (62.1%) who were triaged to rehabilitation services or supervised exercise completed the referral. Postsurgery, 23 of 34 patients (62.1%) completed the referral.

The results reported by Simon et al. demonstrate the feasibility of incorporating a screening, triage, and referral process into the clinical care of patients undergoing breast surgery. In addition to the high rates of survey completion at both the presurgery and postsurgery timepoints, qualitative interviews with clinical staff at the enrolling site indicated that “CORE did not affect normal clinical operations” and that “administering the tool at patient check-in was deemed appropriate.” However, it should be noted that the population of patients taking part in the program was small and that only 72 of the 261 (27.5%) potentially eligible patients approached were consented to participate in the study.

Several other recent efforts have evaluated the feasibility of incorporating exercise triage into oncology care. One recent initiative implemented the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) Algorithm,⁸ an evidence-based decision support tool developed by a multidisciplinary team (including oncology clinicians, exercise physiologists, physical therapists and occupational therapists), to triage and refer patients to personalized rehabilitation and exercise programs by providing practical, step-by-step guidance tailored to individualized needs based on patients’ disease side effects, functional factors, and behavioral factors.^8-10 In this quality improvement project, medical assistants administered the EXCEEDS triage survey to patients attending their second chemotherapy infusion visit. Over a six-month period, 501 of 587 (85.3%) patients visiting the infusion clinics were offered the triage survey, with 391 patients (78%) completing it. Among those triaged, 176 (45%) were connected to exercise or rehabilitation interventions, demonstrating successful incorporation of the EXCEEDS tool into clinical workflow. In another quality improvement project, assessment of exercise behaviors and functional status was incorporated into the electronic health record as part of a program called My Wellness Check-in. Between April 2021 and May 2022, 1174 patients completed the assessment. Almost half of these individuals (46%) triggered an alert due to insufficient physical activity. However, only 31% of these patients received a completed referral to cancer rehabilitation medicine and only 8% of referred patients accessed specialized rehabilitation services. These findings demonstrate the feasibility of incorporating triage systems into oncology care, but highlight the gap between identification of patient need and actual utilization.¹¹

Efforts to incorporate exercise into oncology care require not only successful screening, triage, and referral but also the availability of exercise programs that provide an appropriate level of support for patients with cancer across a wide range of functional capacities. In the study by Simon et al., patients were triaged to rehabilitation services, a supervised exercise program provided by the cancer center, or self-directed exercise. Notably, only patients who currently met guidelines for both aerobic and resistance training exercise and who had a Patient-Reported Outcomes Measurement System score >50 (indicating no functional impairment) were assigned to self-directed exercise. Only 18% of participants were assigned to this group preoperatively, whereas 56.8% were triaged to supervised exercise, and 9.1% were triaged to rehabilitation services. At the postoperative visit, only 2.5% of participants were triaged to self-directed exercise, 40% were triaged to supervised exercise, and 45% were triaged to rehabilitation services. Similarly, in the project reported by Schmitz et al., only 27.9% of patients receiving chemotherapy who completed the EXCEEDS tool met criteria for community-based exercise, highlighting the need for specialized exercise programs for patients with cancer.⁸

Given these findings, it is notable that only a small proportion of oncology clinics offer structured and specialized exercise services. A 2024 study investigated the availability of cancer survivorship support services across the National Cancer Institute Community Oncology Research Program (NCORP) network and found that only 63 of 259 (24%) adult practice groups from 46 National Cancer Institute Community Oncology Research Program community sites offered exercise and/or rehabilitation programs.¹² Reimbursement and funding barriers remain significant obstacles as insurance coverage for structured exercise oncology programs is limited. Many cancer centers provide exercise programs for their patients, and there are a few national models, such as LIVESTRONG at the YMCA, that offer structured exercise support specifically tailored for cancer survivors. However, these programs typically rely heavily on donor funding and community partnerships rather than consistent reimbursement mechanisms. This funding structure poses sustainability challenges and limits the widespread availability of such valuable services. The American College of Sports Medicine launched a task force in 2021 to explore pathways to secure reimbursement for exercise physiology in oncology care settings.¹³ Advocacy efforts are needed to push for policy changes that recognize exercise as an essential component of cancer care to improve reimbursement policies, ensure financial sustainability of programs, and expand patient access to structured, evidence-based exercise interventions.

The integration of multidisciplinary triage and referral systems in oncology care represents a critical step toward bridging the gap between evidence-based exercise recommendations and clinical practice. The CORE clinical workflow algorithm demonstrates the feasibility and acceptability of embedding exercise and rehabilitation services into routine cancer care. Future work is needed to test the scalability of exercise triage systems in oncology care, potentially incorporating decision-support tools within electronic health records to help guide oncology teams in identifying appropriate exercise referrals based on a patient's treatment status, functional limitations, and comorbidities.⁹ In addition, to fully realize the benefits of exercise oncology, further efforts are needed to increase the availability of oncology exercise services and improve reimbursement policies. By addressing these challenges, the integration of exercise and rehabilitation programs into comprehensive cancer care could ultimately improve outcomes and quality of life for patients across the oncology spectrum.

The authors declared no conflicts of interest.