Sedentary Behavior and Prostate Cancer: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

Associations of role, area deprivation index, and race with health behaviors and body mass index among localized prostate cancer patients and their partners

PURPOSE

To examine the associations of role (localized prostate cancer (PCa) patient vs. their intimate partner), area deprivation index (ADI-higher scores indicating higher neighborhood deprivation levels), and race (Black/African American (AA) vs. White) with health behaviors and body mass index (BMI) among PCa patients and partners. The behaviors include smoking, alcohol consumption, diet quality, sedentary behaviors, and physical activity (PA).

METHODS

This study used the baseline data collected in a clinical trial. Given the nested structure of the dyadic data, multi-level models were used.

RESULTS

Significant role-race interaction effects on smoking, ADI-race effects on alcohol consumption, and role-ADI effects on BMI were found. Meanwhile, patients smoked more cigarettes, decreased alcohol consumption, had less healthful diets, spent longer time watching TV, did fewer sedentary hobbies, had more confidence in PA, and had higher BMIs than their partners. High ADI was independently associated with lower odds of drinking alcohol, using computer/Internet, and doing non-walking PA, and higher BMI compared to low ADI controlling for role and race. Black/AA dyads had less smoking amount and alcohol consumption and higher sedentary time and BMI than White dyads when adjusted for role and ADI.

CONCLUSIONS

This study identified significant interaction and main effects of role, ADI, or race on health behaviors and BMI.

IMPLICATIONS FOR CANCER SURVIVORS

Future behavioral interventions should address divergent individual needs between patients and partners, social and neighborhood barriers, and cultural indicators of racial groups to promote healthful behaviors and improve the quality of survivorship for PCa patients and partners.

Risk factors for prostate cancer: An umbrella review of prospective observational studies and mendelian randomization analyses

BACKGROUND

The incidence of prostate cancer is increasing in older males globally. Age, ethnicity, and family history are identified as the well-known risk factors for prostate cancer, but few modifiable factors have been firmly established. The objective of this study was to identify and evaluate various factors modifying the risk of prostate cancer reported in meta-analyses of prospective observational studies and mendelian randomization (MR) analyses.

METHODS AND FINDINGS

We searched PubMed, Embase, and Web of Science from the inception to January 10, 2022, updated on September 9, 2023, to identify meta-analyses and MR studies on prostate cancer. Eligibility criteria for meta-analyses were (1) meta-analyses including prospective observational studies or studies that declared outcome-free at baseline; (2) evaluating the factors of any category associated with prostate cancer incidence; and (3) providing effect estimates for further data synthesis. Similar criteria were applied to MR studies. Meta-analysis was repeated using the random-effects inverse-variance model with DerSimonian-Laird method. Quality assessment was then conducted for included meta-analyses using AMSTAR-2 tool and for MR studies using STROBE-MR and assumption evaluation. Subsequent evidence grading criteria for significant associations in meta-analyses contained sample size, P values and 95% confidence intervals, 95% prediction intervals, heterogeneity, and publication bias, assigning 4 evidence grades (convincing, highly suggestive, suggestive, or weak). Significant associations in MR studies were graded as robust, probable, suggestive, or insufficient considering P values and concordance of effect directions. Finally, 92 selected from 411 meta-analyses and 64 selected from 118 MR studies were included after excluding the overlapping and outdated studies which were published earlier and contained fewer participants or fewer instrument variables for the same exposure. In total, 123 observational associations (45 significant and 78 null) and 145 causal associations (55 significant and 90 null) were categorized into lifestyle; diet and nutrition; anthropometric indices; biomarkers; clinical variables, diseases, and treatments; and environmental factors. Concerning evidence grading on significant associations, there were 5 highly suggestive, 36 suggestive, and 4 weak associations in meta-analyses, and 10 robust, 24 probable, 4 suggestive, and 17 insufficient causal associations in MR studies. Twenty-six overlapping factors between meta-analyses and MR studies were identified, with consistent significant effects found for physical activity (PA) (occupational PA in meta: OR = 0.87, 95% CI: 0.80, 0.94; accelerator-measured PA in MR: OR = 0.49, 95% CI: 0.33, 0.72), height (meta: OR = 1.09, 95% CI: 1.06, 1.12; MR: OR = 1.07, 95% CI: 1.01, 1.15, for aggressive prostate cancer), and smoking (current smoking in meta: OR = 0.74, 95% CI: 0.68, 0.80; smoking initiation in MR: OR = 0.91, 95% CI: 0.86, 0.97). Methodological limitation is that the evidence grading criteria could be expanded by considering more indices.

CONCLUSIONS

In this large-scale study, we summarized the associations of various factors with prostate cancer risk and provided comparisons between observational associations by meta-analysis and genetically estimated causality by MR analyses. In the absence of convincing overlapping evidence based on the existing literature, no robust associations were identified, but some effects were observed for height, physical activity, and smoking.

Approaches to Prevent and Manage Cardiovascular Disease in Patients Receiving Therapy for Prostate Cancer

PURPOSE OF REVIEW

Prostate cancer (PCa) is amongst the most common cancers in men worldwide. Cardiovascular (CV) risk factors and CV disease (CVD) are common comorbidities in this patient population, posing a challenge for PCa-directed therapies which can cause or worsen CVRFs and CVDs. Herein, we summarize the approaches to prevent and manage CVD in patients with PCa receiving therapy.

RECENT FINDINGS

While patients with locally advanced and metastatic PCa benefit from hormonal therapy, these treatments can potentially cause CV toxicity. Androgen receptor targeting therapies, such as androgen deprivation therapy (ADT), can induce metabolic changes and directly impact cardiovascular function, thereby reducing cardiorespiratory fitness and increasing CV mortality. Moreover, more than half of the PCa patients have poorly controlled CV risk factors at baseline. Hence, there is an urgent need to address gaps in preventing and managing CVD in PCa patients. Screening and optimizing CV risk factors and CVD in patients undergoing ADT are essential to reduce CV mortality, the leading non-cancer cause of death in PCa survivors. The risk of CV morbidity and mortality can be further mitigated by considering the patient's cardiovascular risk profile when deciding the choice and duration of ADT. A multidisciplinary team-based approach is crucial to achieve the best outcomes for PCa patients undergoing therapy.

2022 Update on Prostate Cancer Epidemiology and Risk Factors-A Systematic Review

CONTEXT

Prostate cancer (PCa) is one of the most common cancers worldwide. Understanding the epidemiology and risk factors of the disease is paramount to improve primary and secondary prevention strategies.

OBJECTIVE

To systematically review and summarize the current evidence on the descriptive epidemiology, large screening studies, diagnostic techniques, and risk factors of PCa.

EVIDENCE ACQUISITION

PCa incidence and mortality rates for 2020 were obtained from the GLOBOCAN database of the International Agency for Research on Cancer. A systematic search was performed in July 2022 using PubMed/MEDLINE and EMBASE biomedical databases. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and was registered in PROSPERO (CRD42022359728).

EVIDENCE SYNTHESIS

Globally, PCa is the second most common cancer, with the highest incidence in North and South America, Europe, Australia, and the Caribbean. Risk factors include age, family history, and genetic predisposition. Additional factors may include smoking, diet, physical activity, specific medications, and occupational factors. As PCa screening has become more accepted, newer approaches such as magnetic resonance imaging (MRI) and biomarkers have been implemented to identify patients who are likely to harbor significant tumors. Limitations of this review include the evidence being derived from meta-analyses of mostly retrospective studies.

CONCLUSIONS

PCa remains the second most common cancer among men worldwide. PCa screening is gaining acceptance and will likely reduce PCa mortality at the cost of overdiagnosis and overtreatment. Increasing use of MRI and biomarkers for the detection of PCa may mitigate some of the negative consequences of screening.

PATIENT SUMMARY

Prostate cancer (PCa) remains the second most common cancer among men, and screening for PCa is likely to increase in the future. Improved diagnostic techniques can help reduce the number of men who need to be diagnosed and treated to save one life. Avoidable risk factors for PCa may include factors such as smoking, diet, physical activity, specific medications, and certain occupations.

The association between sexual dysfunction and prostate cancer: a systematic review and meta-analysis

BACKGROUND

Whether there is a connection between sexual dysfunction (SD) and prostate cancer (PCa) is controversial.

AIM

We sought to review the interrelationship between SD and PCa and to determine whether there is a definitive risk of men developing PCa after suffering from SD.

METHODS

A complete search of the PubMed, Web of Science, Ovid MEDLINE, Embase, and Cochrane Library databases was performed to search for eligible studies published up to October 2022. The protocol for this meta-analysis is available from PROSPERO (ID: CRD42022342381).

OUTCOMES

The associations between SD and the risk of PCa were assessed by calculating pooled ORs with 95% CIs, and the standard mean difference (SMD) and its 95% CI were used to assess the relationship between SD and prostate-specific antigen (PSA) levels or prostate volume (PV). Random-effects models were used to account for potential heterogeneity, and the Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the included studies.

RESULTS

Twenty studies involving 215,626 individuals were included in our meta-analysis. Compared with controls, subjects with SD had a 1.62-fold increased risk of PCa (OR = 1.62, 95% CI, 1.77-2.23, P = .003; heterogeneity: I2 = 97.8%, P < .001). Patients with SD had higher PSA levels than controls (SMD =0.07, 95% CI, 0.00 to 0.13, P = .041; heterogeneity: I2 = 55.6%, P = .027). However, there was no association between SD and PV (SMD = 0.03, 95% CI, -0.05 to 0.11, P = .122; heterogeneity: I2 = 48.5%, P = .100).

CLINICAL IMPLICATIONS

Current evidence confirms a potential link between SD and the risk of PCa and that SD in PCa patients should be of concern to clinicians.

STRENGTHS AND LIMITATIONS

The strength of this study is that it is to our knowledge the first meta-analysis of studies on the risk of PCa in men with SD. A limitation is that most of the studies included in this meta-analysis focused on ED.

CONCLUSION

Our systematic review and meta-analysis results suggest that men with SD have a higher risk of PCa and higher PSA levels than men without SD. However, this is merely inferential, and causality cannot be determined based on the current data. Further longitudinal studies should be performed to validate our preliminary findings.

Modifiable risk factors for prostate cancer in low- and lower-middle-income countries: a systematic review and meta-analysis

BACKGROUND

Most of the epidemiological data on prostate cancer risk factors come from high-income countries (HIC). Reducing exposure to prostate cancer modifiable risk factors may significantly lower PCa morbidity and mortality in LIC and MIC. The objective of this study was to summarize the evidence on modifiable risk factors (RFs) for PCa in LIC and lower-middle-income countries (LMIC).

METHODS

We conducted a systematic search on MEDLINE, EMBASE, and Global Health databases. We selected case-control and cohort studies from 2010 onwards that studied modifiable RFs for PCa in LIC and LMIC with a population of 30 million or more, as defined by the World Bank in January 2021. Risk of bias was assessed by the Ottawa-Newcastle tool. Individual study estimates were pooled when estimates were available for at least two studies.

RESULTS

5740 studies were initially identified; 16 studies met inclusion criteria. All were case-control studies except one retrospective cohort study. Higher fat intake was associated with a higher risk of PCa incidence with an odds ratio (OR) of 3.13 (95% CI 1.33-7.33). Higher vegetable intake (OR 0.48, 95% CI 0.24-0.97) and tea consumption (OR 0.51, 95% CI 0.32-0.83) were associated with a lower risk for PCa. There was no association between fruits, fish, and chicken consumption and risk of PCa. Alcohol consumption, smoking, red meat intake, and a BMI ≥ 25-30 kg/m² showed a trend towards an increased risk, although these were not statistically significant.

CONCLUSIONS

In LIC and LMIC, high fat intake was associated with higher risk of PCa while a diet rich in vegetables and tea intake was associated with a lower risk. Future prospective studies will be important to elucidate whether other modifiable risk factors for PCa specific to LIC and LMIC can be identified to inform impactful and cost-effective preventive strategies in these countries.

Associations of sedentary time and physical activity with adverse health conditions: Outcome-wide analyses using isotemporal substitution model

Background

As one of the most common lifestyles today, sedentary behaviour is a risk factor for many health conditions. To inform potential behavioural guideline development, we aimed to estimate the theoretical effects of replacing sedentary behaviour with different intensity of physical activity on risks of 45 common non-communicable diseases (NCDs).

Methods

A total of 360,047 participants (aged 37-73 years) in the UK Biobank free of the 45 common non-communicable diseases (NCDs) were included. Information on sedentary time (sum of television watching, computer using and driving behaviour) and physical activity (measured by International Physical Activity Questionnaire questionnaire) were collected by self-reported at baseline. Participants were followed up for 45 NCDs diagnosis according to the ICD-10 code using linkage to national health records until 2020. Isotemporal substitution models were used to investigate substituting sedentary time with light physical activity (LPA), moderate physical activity (MPA) and vigorous physical activity (VPA) after adjusting for potential confounders.

Finding

Participants who reported > 6 h/day compared with ≤ 2 h/day sedentary time had higher risks of 12 (26.7%) of 45 NCDs, including ischemic heart disease, diabetes, chronic obstructive pulmonary disease, asthma, chronic kidney disease, chronic liver disease, thyroid disorder, depression, migraine, gout, rheumatoid arthritis and diverticular disease. Theoretically, replacing sedentary time with equivalent LPA, MPA and VPA was associated with risk reductions in 4, 6 and 10 types of NCDs, respectively. Among long sedentary time (> 6 h/day), replacing 1 h/day sedentary time with equivalent VPA showed stronger associations with 5 NCDs (diabetes, depression, chronic liver disease, diverticular disease and sleep disorder), with a larger risk reduction of 11%-31%.

Interpretation

Sedentary time is associated with multiple adverse health conditions, replacing sedentary time with any equivalent amounts of VPA than LPA and MPA could be associated with risk reductions of more types of NCDs.

Funding

National Natural Science Foundation of China.

Sedentary behavior and cancer-an umbrella review and meta-analysis

Several systematic reviews and meta-analyses have summarized the association between sedentary behavior (SB) and cancer. However, the level of evidence and the potential for risk of bias remains unclear. This umbrella review summarized the current data on SB in relation to cancer incidence and mortality, with a particular emphasis on assessing the risk of bias. We searched PubMed, Web of Science and Cochrane Database for systematic reviews and meta-analyses on the association between SB and cancer incidence and mortality. We also searched for recent observational studies not yet included in existing meta-analyses. We re-calculated summary risk estimates for cancer incidence and mortality using random effects models. We included 14 meta-analyses covering 17 different cancer sites from 77 original studies. We found that high SB levels increase the risk for developing ovarian, endometrial, colon, breast, prostate, and rectal cancers, with relative risks of 1.29 (95% confidence interval (CI) = 1.08-1.56), 1.29 (95% CI = 1.16-1.45), 1.25 (95% CI = 1.16-1.33), 1.08 (95% CI = 1.04-1.11), 1.08 (95% CI = 1.00-1.17), and 1.07 (95% CI = 1.01-1.12), respectively. Also, we found an increased risk of cancer mortality of 1.18 (95% CI = 1.09-1.26). Most associations between SB and specific cancer sites were supported by a "suggestive" level of evidence. High levels of SB are associated with increased risk of several types of cancer and increased cancer mortality risk.

Association between schizophrenia and prostate cancer risk: Results from a pool of cohort studies and Mendelian randomization analysis

BACKGROUND

Observational studies analyzing the risk of prostate cancer in schizophrenia patients have generated mixed results. We performed a meta-analysis and a Mendelian randomization (MR) analysis to evaluate the relationship and causality between schizophrenia and the risk of prostate cancer.

METHODS

A comprehensive and systematic search of cohort studies was conducted, and a random-effects model meta-analysis was performed to calculate the standardized incidence ratios (SIRs) for prostate cancer incidence among schizophrenia patients versus the general population. To investigate the correlation between genetically-predicted schizophrenia and prostate cancer risk, we used summary statistics from the Prostate Cancer Association Group to Investigate Cancer Associated Alterations in the Genome (PRACTICAL) consortium (61,106 controls and 79,148 cases), and 75 schizophrenia-associated single nucleotide polymorphisms (SNP) from European descent as the instrumental variable.

RESULTS

In the meta-analysis of 13 cohort studies with 218,076 men involved, a decreased risk of prostate cancer was observed among schizophrenia patients [SIR 0.610; 95% confidence interval (CI) 0.500-0.740; p < 0.001] with significant heterogeneity (I² = 83.3%; p < 0.001). However, MR analysis did not sustain the link between genetically-predicted schizophrenia and prostate cancer [odds ratio (OR) 1.033; 95% CI 0.998-1.069; p = 0.065]. The result was robust against extensive sensitivity analyses.

CONCLUSIONS

Our study indicated a decreased risk of prostate cancer in schizophrenia patients through meta-analysis, while MR analysis did not support the connection between schizophrenia and prostate cancer. Due to the interaction of genetic variants between binary exposures, we need to be cautious in interpreting and presenting causal associations. Moreover, further research is needed to investigate underlying factors that might link schizophrenia to the risk of prostate cancer.

Factors Influencing Care Pathways for Breast and Prostate Cancer in a Hospital Setting

Breast cancer (BCa) and prostate cancer (PCa) are the most prevalent types of cancers. We aimed to understand and analyze the care pathways for BCa and PCa patients followed at a hospital setting by analyzing their different treatment lines. We evaluated the association between different treatment lines and the lifestyle and demographic characteristics of these patients. Two datasets were created using the electronic health records (EHRs) and information collected through semi-structured one-on-one interviews. Statistical analysis was performed to examine which variable had an impact on the treatment each patient followed. In total, 83 patients participated in the study that ran between January and November 2018 in Beacon Hospital. Results show that chemotherapy cycles indicate if a patient would have other treatments, i.e., patients who have targeted therapy (25/46) have more chemotherapy cycles (95% CI 4.66–9.52, p = 0.012), the same is observed with endocrine therapy (95% CI 4.77–13.59, p = 0.044). Patients who had bisphosphonate (11/46), an indication of bone metastasis, had more chemotherapy cycles (95% CI 5.19–6.60, p = 0.012). PCa patients with tall height (95% CI 176.70–183.85, p = 0.005), heavier (95% CI 85.80–99.57, p < 0.001), and a BMI above 25 (95% CI 1.85–2.62, p = 0.017) had chemotherapy compared to patients who were shorter, lighter and with BMI less than 25. Initial prostate-specific antigen level (PSA level) indicated if a patient would be treated with bisphosphonate or not (95% CI 45.51–96.14, p = 0.002). Lifestyle variables such as diet (95% CI 1.46–1.85, p = 0.016), and exercise (95% CI 1.20–1.96, p = 0.029) indicated that healthier and active BCa patients had undergone surgeries. Our findings show that chemotherapy cycles and lifestyle for BCa, and tallness and weight for PCa may indicate the rest of treatment plan for these patients. Understanding factors that influence care pathways allow a more person-centered care approach and the redesign of care processes.

Associating the risk of three urinary cancers with obesity and overweight: an overview with evidence mapping of systematic reviews

BACKGROUND

The relationship between cancer with overweight and obesity has been extensively reported. However, the association between urinary cancers with these risk factors remains unclear, with existing reports showing conflicting findings. The current review, therefore, sought to clarify the latter association by assessing the methodological and reporting quality of existing systematic reviews on the subject.

METHODS

We first screened PubMed, EMBASE, and Cochrane Library databases for relevant literature and subjected the resulting articles to meta-analysis. We adopted the AMSTAR-2 and PRISMA checklists for assessing methodological and reporting quality, respectively, then performed meta-analyses to determine the relationship between incidence and mortality of three types of urinary cancers with obesity and overweight. Indirect comparisons were also done across subgroups.

RESULTS

All systematic reviews (SRs) were of critically low methodological quality. Seventeen SRs had minimal reporting flaws, and 11 SRs had minor reporting flaws. We found an association between obesity with an incidence of kidney (RR = 1.68, 95% CI 1.47-1.92), bladder (RR = 1.1, 95% CI 1.07-1.13), and prostate (RR = 1.02, 95% CI 0.91, 1.13) cancers. Similarly, overweight was associated with the incidence of the three types of cancer, recording RR values of 1.37 (95% CI 1.26-1.48), 1.07 (95% CI 1.03-1.1), and 1 (95% CI 0.93, 1.07) for kidney, bladder, and prostate cancers, respectively. With regard to the dose analysis, the RR of BMI (per 5 kg/m2 increase) was associated with kidney (RR = 1.24, 95% CI 1.2-1.28), bladder (RR = 1.03, 95% CI 1.02-1.05), and prostate (RR = 1.02, 95% CI 1.01, 1.03) cancers.

CONCLUSIONS

This comprehensive quantitative analysis provides an affirmation that overweight and obesity are strong risk factors for kidney cancer, owing to a strong association between them. Conversely, a weak association between overweight and obesity with bladder and prostate cancers confirms their status as mild risk factors for the 2 types of cancer. But due to the low quality of included SRs, the results need to be interpreted with caution.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019119459.

New global guidelines on sedentary behaviour and health for adults: broadening the behavioural targets

BACKGROUND

In 2018, the World Health Organisation (WHO) commenced a program of work to update the 2010 Global Recommendations on Physical Activity for Health, for the first-time providing population-based guidelines on sedentary behaviour. This paper briefly summarizes and highlights the scientific evidence behind the new sedentary behaviour guidelines for all adults and discusses its strengths and limitations, including evidence gaps/research needs and potential implications for public health practice.

METHODS

An overview of the scope and methods used to update the evidence is provided, along with quality assessment and grading methods for the eligible new systematic reviews. The literature search update was conducted for WHO by an external team and reviewers used the AMSTAR 2 (Assessment of Multiple Systematic Reviews) tool for critical appraisal of the systematic reviews under consideration for inclusion. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to rate the certainty (i.e. very low to high) of the evidence.

RESULTS

The updated systematic review identified 22 new reviews published from 2017 up to August 2019, 14 of which were incorporated into the final evidence profiles. Overall, there was moderate certainty evidence that higher amounts of sedentary behaviour increase the risk for all-cause, cardiovascular disease (CVD) and cancer mortality, as well as incidence of CVD, cancer, and type 2 diabetes. However, evidence was deemed insufficient at present to set quantified (time-based) recommendations for sedentary time. Moderate certainty evidence also showed that associations between sedentary behaviour and all-cause, CVD and cancer mortality vary by level of moderate-to-vigorous physical activity (MVPA), which underpinned additional guidance around MVPA in the context of high sedentary time. Finally, there was insufficient or low-certainty systematic review evidence on the type or domain of sedentary behaviour, or the frequency and/or duration of bouts or breaks in sedentary behaviour, to make specific recommendations for the health outcomes examined.

CONCLUSIONS

The WHO 2020 guidelines are based on the latest evidence on sedentary behaviour and health, along with interactions between sedentary behaviour and MVPA, and support implementing public health programmes and policies aimed at increasing MVPA and limiting sedentary behaviour. Important evidence gaps and research opportunities are identified.

Improving Physical and Mental Health in Patients with Prostate Cancer Undergoing Androgen Deprivation Therapy: Strategies to Promote and Improve Physical Activity Quality and Quantity

OBJECTIVE

Prostate cancer continues to be one of the highest-incident cancers among men. Reducing serum testosterone with androgen deprivation therapy (ADT) is a common effective treatment. While well-demonstrated for cancer suppression, there are numerous adverse effects caused by ADT that can contribute to short- and long-term prognosis. Increased levels of physical activity (PA) during treatment may reduce these side effects. However, uptake of PA is low. The purpose of this review is to identify and evaluate the current literature on strategies to promote and increase the levels of PA in patients with prostate cancer undergoing ADT.

DATA SOURCES

Electronic databases including CINAHL, MEDLINE, PsychINFO, Scopus, and grey literature were searched using Google Scholar up until April 2020.

CONCLUSION

At present the most appropriate modes and dosages of PA for specific ADT toxicities is not known. It is established that some PA in the form of exercise, whether aerobic or resistance, is better than being sedentary for improvements in physical health, but beyond this prescription specifics have not been established. Further research is required to understand the impact of PA on the mental and physical health of men with prostate cancer undergoing ADT.

IMPLICATIONS FOR NURSING PRACTICE

Being physically active and avoiding sedentary behaviour is important for men with prostate cancer undergoing ADT, especially the implementation of strength training. PA in the form of exercise can assist in reducing the adverse physical side effects in the short- and long-term, with limited understanding of the effects on mental health. PA improves mental health outcomes across populations, which may also translate to men with prostate cancer, although further research is required. An important strategy to improve PA within the prostate cancer population is to provide an early referral to an exercise professional, such as an accredited exercise physiologist/clinical exercise physiologist or physical therapist/physiotherapist, and is supported by research as best practice for people affected by cancer undergoing active treatment.