Moving forward: Strategies for general practitioners to encourage physical activity in people living with and beyond cancer

Physical activity (PA; ie any movement produced by skeletal muscles requiring energy expenditure)¹ and exercise (ie planned, structured and repetitive PA for the purpose of improving health and maintaining fitness)¹ have numerous benefits for people diagnosed with cancer. Those affected by cancer who engage in PA have been shown to have improved sleep quality, muscle mass and cardiorespiratory fitness, and a reduced risk of cancer recurrence and mortality.² PA accumulated in both supervised and home-based settings has been shown to mitigate cancer-related fatigue, one of the most common debilitating symptoms in patients during and after treatment.^3,4 Participating in PA can provide psychological benefits by reducing symptoms of anxiety and depression, which is a significant benefit for those facing the uncertainty that comes with a cancer diagnosis.⁵ PA is even safe and effective for patients facing challenging clinical trajectories, including improving postoperative functional capacity and reducing hospital complication rates in those presurgery (‘prehabilitation’),⁶ and improves quality of life, fatigue, fitness and strength in patients living with advanced or palliative cancers.⁷ However, with 67% of cancer survivors not meeting PA guidelines,⁸ it is important and timely that the 151,000 Australians diagnosed with cancer annually are supported to increase their PA.⁹

There are urgent calls from national oncology organisations to embed PA into healthcare starting from diagnosis, including primary care (Table 1).^10,11 Australia is well positioned to be the first country globally to successfully embed PA into cancer care. Australia developed the first exercise–oncology position statement¹⁰ and federally funds physiotherapy and exercise physiology services that deliver PA programs for chronic diseases, including cancer. Given the growing evidence base, this article was created to support general practitioners (GPs) to promote PA for their patients during and after cancer. This is in addition to encouraging GPs to provide resources and support within the limited consultation time frame and be equipped with knowledge of available health professionals and programs for referrals, as indicated.

GPs play an integral role in shared cancer follow-up care and are well positioned to implement PA through informing patients about the benefits of PA, supporting them to overcome any barriers and become active, and referring those patients in need to exercise professionals experienced in cancer care. Given the significant barriers that GPs face with time and competing priorities within consultations, we recommend evidence-based interventions, including brief advice or counselling on the benefits of PA, with supporting written or video material (eg from the Cancer Council), a PA prescription, differentiation between different PA intensities and/or referral to an exercise professional or program (Box 1).^10,12–18 Simple recommendations include starting a comfortably paced walking program, progressing to brisk walking. Informing patients about the benefits of even small amounts of vigorous PA (ie four minutes of brisk walking) throughout the day is another simple tool to reduce cancer mortality risk by 30%.¹⁶ Some patients might benefit by monitoring their steps using pedometers or other wearables. GPs can monitor and create step targets that are incremental and agreed with the patient. Given the lower mortality risk for every increasing 2000-step interval up to 10,000 steps/day,¹⁷ patients can benefit by achieving smaller targets to their own capabilities. Other inexpensive suggestions for aerobic exercise include stair climbing, swimming and incorporating hills into walking routes, and suggestions for resistance exercise include chair squats, lifting tin cans and using resistance bands. Free mobile phone applications (eg Google Fit) can be other useful tools to motivate patients to become active.

Patients might present with numerous barriers to initiating PA, including treatment-related side effects, fatigue and uncertainty about which type of PA program will be safe and beneficial for them.¹⁹ These patients might benefit from closer and individualised support from Australia’s growing workforce of accredited exercise physiologists (AEPs) and physiotherapists, whereas patients with more complex medical needs can be considered for referral to a sport and exercise physician (Box 2). Such exercise professionals are qualified to safely prescribe PA to clinical populations, with examples of exercise programs commonly prescribed in cancer care focusing on managing treatment side effects, such as debilitating cancer-related fatigue,²⁰ or improving balance and stability deficits caused by chemotherapy-induced peripheral neuropathy.²¹ Services might be offered in person or through telehealth, which can be beneficial for some regional communities and immunocompromised patients, while those with poor internet access or no access to physical programs can utilise the Get Healthy NSW Cancer Support Program with free health coaching over the telephone (Table 2).

AEP and physiotherapy sessions are subsidised by enhanced primary care programs. However, with only five sessions provided annually across all allied health, this is insufficient for people with multimorbidities (eg those who need dietetics or podiatry), and the rebate might not fully cover the cost. Many private health insurers fund exercise professionals. However, for patients without private health insurance, affording exercise professionals might be more onerous. Importantly, there are numerous free and subsidised community PA programs for people living with or beyond cancer that can be accessed through GP referral or self-referral (Table 2). Thus, one recommendation is to concurrently encourage self-directed PA and offer referral into a community program (eg Cancer Council and parkrun).

Given that referral pathways between tertiary cancer and community exercise professionals and programs are not established nationwide, GPs are in a pivotal position to bridge this gap when patients transition to community care by discussing, recommending and referring PA. This aligns with Australian guidelines, where all health professionals are recommended to promote PA to people diagnosed with cancer within the constraints of our healthcare system.¹⁰ Given exercise interventions can lower the economic burden of chronic disease ($10.50 benefit for every $1 spent),²² there has never been a better time to harmonise available services and resources to assist the 151,000 Australians diagnosed with cancer annually to become physically active.⁹