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

Social distancing due to the coronavirus disease 2019 (COVID-19) pandemic has forced clinicians and their patients with cancer to adapt in numerous ways. A new study from the Wright State University Department of Kinesiology and Health and the Maple Tree Cancer Alliance, both in Dayton, Ohio, and the Department of Public Health Sciences at the Penn State College of Medicine in Hershey, Pennsylvania, investigated the feasibility, acceptability, and effectiveness of remote exercise programming in lieu of group programs. The findings, published in Current Sports Medicine Reports (2021;20:271-276. 10.1249/JSR.0000000000000846), show benefits in physical and psychological outcomes, and the authors conclude that the remote intervention is a suitable option when in-person exercise training is not feasible.

Researchers evaluated 491 patients undergoing antineoplastic treatment at Kettering Medical Center in Dayton, Ohio, between March and June 2020 who were enrolled in a cancer exercise program for people living with and beyond cancer that was provided at no cost through the nonprofit Maple Tree Cancer Alliance.

Most of the participants (n = 423) were enrolled at the Maple Tree Cancer Alliance before the start of COVID-19–related social distancing. The remaining patients began the exercise program in a virtual format in March 2020. Their ages ranged from 14 to 83 years, with a mean age of 60 years. Eighty-four percent were female; 74.7% were White, 10.2% were African American, 3.9% were Hispanic, and 5.7% were Asian. The ethnicity of the rest was unknown. Most had breast (58.2%), colon (4.5%), prostate (2%), or lung cancer (3.9%).

Researchers developed a virtual assessment for each patient to gauge his or her fitness after they investigated the availability of fitness equipment in each participant’s home. They then created an individualized exercise program focusing on individual patient goals.

The patients provided demographic information and their medical history during the initial visit. They also completed a symptom checklist of 35 items to evaluate possible side effects of their cancer treatment. These included physiological items such as pain, coughing, and dizziness as well as emotional symptoms such as well-being and sadness, with participants rating each symptom from 0 (absent) to 10 (very severe). Then, participants met individually with an exercise oncology trainer in a virtual format. Each patient completed 12 weeks of prescribed, individualized exercise. The goal was for participants to complete 150 minutes of cardiovascular training per week, with each session’s duration being approximately 30 minutes; full-body strength training workouts (using free weights, elastic tubing, and/or body weight exercises, depending on availability) involving all major muscle groups; and flexibility training (static stretching). The exercise trainer met virtually with patients once per week but assigned homework to be active on the “off” days, at least 3 days per week.

Because there were varying lengths of time that patients spent during 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 to virtual to in-person. In-person to virtual to virtual. Virtual to in-person. Virtual to virtual. Study Results

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

There were 18 participants (3.5%) who withdrew from the program before completion; almost all cited health and family problems as their reason. There were no adverse events related to virtual training reported by any of the participants. “While the number of total sessions was well over 1000 by nearly 500 patients, there were no injuries reported and no adverse effects,” says senior study author Kathryn Schmitz, PhD, MPH, a distinguished professor in the Department of Public Health Sciences and the Department of Physical Medicine and Rehabilitation at the Penn State College of Medicine in Hershey, Pennsylvania. “This is crucial, because clinicians often slow/stop the referral process for fear of adverse events,” she says.

Overall, patients saw increases in Cardiovascular endurance (15.2%, P < .05). Muscular endurance (18.2%, P < .05). Flexibility (31.9%, P < .05). Feelings of support (58.7%, P < .05). Quality of life (32.2%, P < .05). There were also decreases in Feelings of loneliness (54%, P < .05). Fatigue (48.7%, P < .05).

Patients who completed a timed “Get Up and Go” assessment (an alternative to a treadmill test for patients who are at risk of falling, covering 10 feet from a chair) improved their time by 27.5%. There were no significant differences in the completion rates among the 4 groups with various combinations of in-person and virtual exercise supervision.

Most participants (67.3%) said that they found the intensity of the virtual exercise program to be similar to that of the in-person program, 12.3% found it to be harder, and the remainder (21.4%) said that it was easier.

Study Interpretation

“Given all we know about the benefits of exercise, especially for patients with cancer, we need to be creative in overcoming new barriers to exercise,” says Erika Rees-Punia, PhD, MPH, principal scientist in the Department of Population Science at the American Cancer Society in Atlanta, Georgia. “This study provides solid evidence for a virtual adaptation of a highly personalized exercise program in a time when in-person solutions are not always safe or feasible.”

Dr. Rees-Punia says that although the pandemic forced clinicians to quickly shift toward technology-based solutions, it is important to consider that these findings may still be very useful in a postpandemic world. “There are likely several other scenarios in research and in the clinic for which individualized virtual training may be appropriate and beneficial. One clear example is the use of virtual training among patients unable to meet in a centralized location, particularly patients living in rural areas or those with limited transportation options.”

Dr. Schmitz says that virtual exercise oncology programs, when delivered by well-trained staff, are feasible, safe, and effective for improving fitness, function, and symptoms. “This matters because clinicians decide whether to continue chemotherapy at the same dose based on function and symptoms at every appointment,” she says. “Exercise is powerful medicine and should be included as standard of care for people receiving cancer treatment.”

Dr. Schmitz adds that this does not mean that there is not more work to do to better understand exercise as a medicine for patients with cancer. “As an analogy: When we develop a new chemo regimen for a particular tumor type that documents effectiveness, we do not stop looking for better agents. Exercise works on many body systems and our understanding of dosing and mechanisms for treatment effects is far from complete. But we also do not withhold the known, effective chemo regimen while waiting for more evidence. So, we should be prescribing exercise for patients with cancer now.”