ASCO

Exercise, Diet, and Weight Management

During Cancer Treatment: ASCO Guideline
special articles
Jennifer A. Ligibel, MD1; Kari Bohlke, ScD2; Anne M. May, PhD3; Steven K. Clinton, MD, PhD4; Wendy Demark-Wahnefried, PhD, RD5;
Susan C. Gilchrist, MD, MS6; Melinda L. Irwin, PhD, MPH7; Michele Late8; Sami Mansfield, BA9; Timothy F. Marshall, PhD, MS10;
Jeffrey A. Meyerhardt, MD, MPH1; Cynthia A. Thomson, PhD, RD11; William A. Wood, MD, MPH12; and Catherine M. Alfano, PhD13
abstract

PURPOSE To provide guidance on exercise, diet, and weight management during active cancer treatment in
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adults.
METHODS A systematic review of the literature identified systematic reviews and randomized controlled trials
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

evaluating the impact of aerobic and resistance exercise, specific diets and foods, and intentional weight loss
and avoidance of weight gain in adults during cancer treatment, on quality of life, treatment toxicity, and cancer
control. PubMed and the Cochrane Library were searched from January 2000 to May 2021. ASCO convened an
Expert Panel to review the evidence and formulate recommendations.
RESULTS The evidence base consisted of 52 systematic reviews (42 for exercise, nine for diet, and one for weight
management), and an additional 23 randomized controlled trials. The most commonly studied types of cancer
were breast, prostate, lung, and colorectal. Exercise during cancer treatment led to improvements in car-
diorespiratory fitness, strength, fatigue, and other patient-reported outcomes. Preoperative exercise in patients
with lung cancer led to a reduction in postoperative length of hospital stay and complications. Neutropenic diets
did not decrease risk of infection during cancer treatment.
RECOMMENDATIONS Oncology providers should recommend regular aerobic and resistance exercise during
active treatment with curative intent and may recommend preoperative exercise for patients undergoing surgery
for lung cancer. Neutropenic diets are not recommended to prevent infection in patients with cancer during
active treatment. Evidence for other dietary and weight loss interventions during cancer treatment was very
limited. The guideline discusses special considerations, such as exercise in individuals with advanced cancer,
and highlights the critical need for more research in this area, particularly regarding diet and weight loss
interventions during cancer treatment.
Additional information is available at [Link]/supportive-care-guidelines.
ASSOCIATED
J Clin Oncol 40:2491-2507. © 2022 by American Society of Clinical Oncology
CONTENT
Appendix
Data Supplement
INTRODUCTION composition during cancer treatment on cancer re-
Author affiliations
and support Obesity, physical inactivity, and low dietary quality are currence or mortality, hundreds of randomized trials
information (if all known risk factors for more than a dozen have demonstrated that these types of lifestyle
applicable) appear changes lead to improvements in other end points,
malignancies.1-3 The World Cancer Research Fund
at the end of this
article.
estimates that 18% of cancers in the United States— such as quality of life (QoL) and treatment-related side
Accepted on April 4,
more than 300,000 cancer cases each year—are effects after cancer diagnosis.8-12
2022 and published at directly attributable to suboptimal diet, low physical
The growing body of observational data showing the
[Link]/journal/ activity, and/or excess adiposity.3 Evidence from ob-
relationship between diet, physical activity, body weight,
jco on May 16, 2022: servational studies also suggests that these factors
DOI [Link] and cancer risk and outcomes, as well as data from
contribute to poor cancer outcomes, especially in
1200/JCO.22.00687 RCTs showing the benefit of healthy lifestyle change
individuals with early-stage breast, colon, and prostate
Evidence Based after cancer diagnosis, have led to the development of
Medicine Committee
cancers.4-7 Although there are very limited data from
approval: March 21, randomized controlled trials (RCTs) testing the impact numerous diet and physical activity guidelines rec-
2022. of weight loss, increased exercise, or changes in diet ommending the incorporation of physical activity,

Volume 40, Issue 22 2491

 Ligibel et al

THE BOTTOM LINE

Exercise, Diet, and Weight Management During Cancer Treatment: ASCO Guideline
Guideline Question
For adult patients with cancer undergoing active treatment with systemic antineoplastic therapy or radiotherapy, or who are in
the perioperative period, do interventions involving exercise, diet, and/or weight control compared with no intervention lead to
meaningful improvements in outcomes related to QoL, treatment toxicity, or cancer control?
Target Population
Adults with cancer receiving systemic antineoplastic therapy or radiotherapy, or who are in the perioperative period. Notably,
this guideline does not include recommendations for individuals with breast cancer being treated with endocrine therapy,
given the extensive representation of this population in other guidelines.
Target Audience
Clinicians who provide care to adults with cancer, as well as patients and caregivers.
Methods
An Expert Panel was convened to develop evidence-based recommendations on the basis of a systematic review of the
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medical literature. Evidence shaping this guidance is derived from systematic reviews of randomized trials of exercise, dietary
modification, and weight management (weight loss or avoidance of weight gain) interventions administered during systemic
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

antineoplastic therapy or radiotherapy, or during the perioperative period. The guideline does not address mind-body exercise
(such as yoga), dietary supplements, cancer cachexia, malnutrition, enteral feeding, or parenteral nutrition.

Recommendations
Question 1: Does exercise during cancer treatment safely improve outcomes related to QoL, treatment toxicity, or cancer
control?
Recommendation 1.1. Oncology providers should recommend aerobic and resistance exercise during active treatment with
curative intent to mitigate side effects of cancer treatment (Type: evidence based, benefits outweigh harms; Evidence quality:
moderate to low; Strength of recommendation: strong).
Note: Exercise interventions during active treatment reduce fatigue; preserve cardiorespiratory fitness, physical functioning,
and strength; and in some populations, improve QoL and reduce anxiety and depression. In addition, exercise interventions
during treatment have low risk of adverse events. Evidence was not sufficient to recommend for or against exercise during
treatment to improve cancer control outcomes (recurrence or survival) or treatment completion rates.
Recommendation 1.2. Oncology providers may recommend preoperative exercise for patients undergoing surgery for lung
cancer to reduce length of hospital stay and postoperative complications (Type: evidence based, benefits outweigh harms;
Evidence quality: low; Strength of recommendation: weak).
Question 2: Does consuming a particular dietary pattern or food(s) during cancer treatment safely improve outcomes related to
QoL, treatment toxicity, or cancer control?
Recommendation 2.1. There is currently insufficient evidence to recommend for or against dietary interventions such as
ketogenic or low-carbohydrate diets, low-fat diets, functional foods, or fasting to improve outcomes related to QoL, treatment
toxicity, or cancer control.
Recommendation 2.2. Neutropenic diets (specifically diets that exclude raw fruits and vegetables) are not recommended to
prevent infection in patients with cancer during active treatment (Type: evidence based, harms likely to outweigh benefits;
Evidence quality: low; Strength of recommendation: weak).
Question 3: Do interventions to promote intentional weight loss or avoidance of weight gain during cancer treatment safely
improve outcomes related to QoL, treatment toxicity, or cancer control?
Recommendation 3. There is currently insufficient evidence to recommend for or against intentional weight loss or prevention
of weight gain interventions during active treatment to improve outcomes related to QoL, treatment toxicity, or cancer control.
Note: The Expert Panel felt strongly that the current lack of evidence regarding diet and weight management interventions
during cancer treatment should be a call to conduct more research in these critical areas. Diet and weight management
strategies that provide health benefits to the general population could also provide important benefits to people who are
undergoing cancer treatment. The Expert Panel is not discouraging clinicians from discussing healthy diet and weight3,13 with
their patients, but did refrain from making specific recommendations, given gaps in the evidence.
(continued on following page)

2492 © 2022 by American Society of Clinical Oncology Volume 40, Issue 22

 Diet, Physical Activity, and Weight Management

THE BOTTOM LINE (CONTINUED)

Additional Resources
Definitions for the quality of the evidence and strength of recommendation ratings are available in Appendix Table A1 (online
only). More information, including slide sets, clinical tools and resources, and a supplement with evidence tables, is available
at [Link]/supportive-care-guidelines. The Methodology Manual (available at [Link]/guideline-methodology)
provides additional information about the methods used to develop this guideline. Patient information is available at
[Link].

ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care, and that all patients
should have the opportunity to participate.

weight management, and dietary modification as a part of METHODS

cancer prevention and control.3,11,12 To date, guidance has Guideline Development Process
generally emphasized population-based public health
guidelines, with a growing focus on at-risk individuals and This systematic review-based guideline was developed by a
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cancer survivors. By contrast, there has been limited effort multidisciplinary Expert Panel, which included a patient
focused upon patients currently undergoing cancer treat- representative and an ASCO guidelines staff member with
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

ment. This time period is critical, given that cancer treatment health research methodology expertise (Appendix Table A2,
often leads to declines in cardiorespiratory fitness and online only). The Expert Panel met via webinar and cor-
physical functioning, unfavorable changes in body compo- responded through e-mail. Based upon the consideration of
sition, and side effects such as neuropathy and fatigue. the evidence, the authors were asked to contribute to the
These side effects can not only adversely affect QoL and development of the guideline, provide critical review, and
functional status after cancer diagnosis, but also predispose finalize the guideline recommendations. The guideline
patients with cancer to comorbidities such as cardiovascular recommendations were sent for an open comment period of
disease and diabetes. two weeks, allowing the public to review and comment on
the recommendations after submitting a confidentiality
Over the past decade, an increasing number of RCTs have agreement. These comments were taken into consideration
tested the impact of exercise, diet, and, to a lesser extent, while finalizing the recommendations. The members of the
weight management interventions on QoL and treatment- Expert Panel were responsible for reviewing and approving
related side effects in patients with cancer receiving a variety the penultimate version of the guideline, which was then
of systemic and local cancer treatments.8-10,12 Assimilating circulated for external review, and submitted to the Journal
these data into evidence-based recommendations is of Clinical Oncology (JCO) for editorial review and consid-
needed, both to best mitigate toxicities of cancer treatment eration for publication. All ASCO guidelines are ultimately
and to provide oncology providers with a framework to help reviewed and approved by the Expert Panel and the ASCO
patients navigate the abundant, often contradictory, infor- Evidence Based Medicine Committee before publication.
mation regarding nutrition, exercise, and weight manage- All funding for the administration of the project was provided
ment for patients with cancer in the lay press. by ASCO.
This ASCO clinical practice guideline seeks to provide The recommendations were developed by using a sys-
evidence-based recommendations regarding exercise, tematic review of evidence identified through online
diet, and weight management interventions in adults un- searches of PubMed and the Cochrane Library for the
dergoing active cancer treatment. period from January 1, 2000, through May 17, 2021. Only
data from RCTs were considered. Systematic reviews of
GUIDELINE QUESTIONS RCTs and individual RCTs were selected for inclusion on
This clinical practice guideline addresses three overarching the basis of the following criteria:
clinical questions: (1) Does exercise during cancer treat- • Population: Adults with cancer who were receiving
ment safely improve outcomes related to QoL, treatment systemic antineoplastic therapy or radiotherapy, or who
toxicity, or cancer control? (2) Does consuming a particular were in the perioperative period. Patients receiving
dietary pattern or food(s) during cancer treatment safely adjuvant endocrine therapy for early-stage breast
improve outcomes related to QoL, treatment toxicity, or cancer were excluded because this literature is already
cancer control? (3) Do interventions to promote intentional summarized in several previous guidelines.11,12 Patients
weight loss or avoidance of weight gain during cancer with head and neck cancer were excluded from the diet
treatment safely improve outcomes related to QoL, treat- systematic review because of their unique nutritional
ment toxicity, or cancer control? challenges.

Journal of Clinical Oncology 2493

 Ligibel et al

• Interventions: Supervised or unsupervised aerobic in clinical decision making. The information herein should
and/or resistance exercise; dietary counseling, specific not be relied upon as being complete or accurate, nor
diets (eg, ketogenic), fasting, functional foods, or other should it be considered as inclusive of all proper treat-
changes to dietary composition; or interventions ments or methods of care or as a statement of the standard
intended to promote weight loss or avoidance of weight of care. With the rapid development of scientific knowl-
gain. Mind-body exercises, dietary supplements (in- edge, new evidence may emerge between the time in-
cluding immunonutrition), and enteral or parenteral formation is developed and when it is published or read.
nutritional support were excluded, as was manage- The information is not continually updated and may not
ment of malnutrition or cachexia. reflect the most recent evidence. The information ad-
• Comparisons: Usual care or a different or less intensive dresses only the topics specifically identified therein and is
diet or exercise intervention. not applicable to other interventions, diseases, or stages of
• Outcomes: Cardiorespiratory fitness, muscle strength, diseases. This information does not mandate any par-
physical functioning, QoL, fatigue, anxiety, depression, ticular course of medical care. Further, the information is
sleep, body weight, body composition, surgical com- not intended to substitute for the independent profes-
plications, chemotherapy or radiotherapy adverse sional judgment of the treating provider, as the information
events, adverse effects of the diet or exercise inter- does not account for individual variation among patients.
ventions, and cancer outcomes such as recurrence Recommendations specify the level of confidence that the
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and survival. recommendation reflects the net effect of a given course of

• Sample size: A minimum of 25 patients per arm action. The use of words like “must,” “must not,” “should,”
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

in RCTs. and “should not” indicates that a course of action is rec-

Articles were excluded from the systematic review if they ommended or not recommended for either most or many
were (1) conference abstracts not subsequently published patients, but there is latitude for the treating physician to
in peer-reviewed journals; (2) editorials, commentaries, select other courses of action in individual cases. In all
letters, news articles, case reports, and narrative reviews; cases, the selected course of action should be considered
(3) published in a non-English language, or (4) a sys- by the treating provider in the context of treating the in-
tematic review that was replaced by a more compre- dividual patient. Use of the information is voluntary. ASCO
hensive, subsequent systematic review. The guideline does not endorse third party drugs, devices, services, or
recommendations were crafted, in part, using the therapies used to diagnose, treat, monitor, manage, or
Guidelines Into Decision Support methodology and ac- alleviate health conditions. Any use of a brand or trade
companying BRIDGE-Wiz software.14 In addition, a review name is for identification purposes only. ASCO provides this
of the ability to implement the guideline was conducted. information on an “as is” basis and makes no warranty,
On the basis of the implementability review, revisions were express or implied, regarding the information. ASCO spe-
made to the draft to clarify recommended actions for cifically disclaims any warranties of merchantability or fit-
clinical practice. Ratings for type and strength of the ness for a particular use or purpose. ASCO assumes no
recommendation, and evidence quality are provided with responsibility for any injury or damage to persons or
each recommendation. The quality of the evidence for property arising out of or related to any use of this infor-
each outcome was assessed using the Cochrane Risk of mation, or for any errors or omissions.
Bias tool and elements of the GRADE quality assessment Guideline and Conflicts of Interest
and recommendations development process.15,16 GRADE
quality assessment labels (ie, high, moderate, low, and The Expert Panel was assembled in accordance with
very low) were assigned for each outcome by the project ASCO’s Conflict of Interest Policy Implementation for
methodologist in collaboration with the Expert Panel co- Clinical Practice Guidelines (“Policy,” found at https://
chairs and reviewed by the full Expert Panel. [Link]/guideline-methodology). All members of
the Expert Panel completed ASCO’s disclosure form, which
The ASCO Expert Panel and guidelines staff will work with requires disclosure of financial and other interests, in-
cochairs to keep abreast of any substantive updates to the cluding relationships with commercial entities that are
guideline. On the basis of formal review of the emerging reasonably likely to experience direct regulatory or com-
literature, ASCO will determine the need to update. The mercial impact as a result of promulgation of the guideline.
ASCO Guidelines Methodology Manual (available at Categories for disclosure include employment; leadership;
[Link]/guideline-methodology) provides additional stock or other ownership; honoraria, consulting or advisory
information about the guideline update process. This is the role; speaker’s bureau; research funding; patents, royalties,
most recent information as of the publication date. other intellectual property; expert testimony; travel, ac-
commodations, expenses; and other relationships. In ac-
Guideline Disclaimer cordance with the Policy, the majority of the members of the
The Clinical Practice Guidelines and other guidance Expert Panel did not disclose any relationships constituting
published herein are provided by ASCO to assist providers a conflict under the Policy.

2494 © 2022 by American Society of Clinical Oncology Volume 40, Issue 22

 Diet, Physical Activity, and Weight Management

RESULTS or against exercise during treatment to improve cancer

Characteristics of Studies Identified in the control outcomes (recurrence or survival) or treatment
Literature Search completion rates.

The literature search of exercise RCTs identified a 2017

Literature review and analysis.
systematic review of systematic reviews,8 which formed the
Fatigue. Meta-analyses in several different types of cancer
starting point for the exercise evidence base. A total of 652
report that exercise during cancer treatment provides a
additional exercise systematic reviews were identified for
moderate reduction in fatigue. In a meta-analysis of 74
the period from January 1, 2017, to June 17, 2021. Forty-
studies with a total of 5,174 patients, Oberoi et al43 reported
two met eligibility criteria and were included in the
a standardized mean difference (SMD) of –0.52; 95% CI,
review.8-10,17-55 The most commonly studied types of cancer
–0.70 to –0.34. Hilfiker et al29 reported a similar or slightly
were breast, prostate, lung, and colorectal. The literature
greater magnitude of benefit in analyses across different
search of diet identified 742 systematic reviews; nine met
types of exercise (aerobic: SMD –0.53; 95% CI, –0.80 to
eligibility criteria and were included in the review.56-64 The
–0.26; resistance: SMD –0.53; 95% CI, –1.02 to –0.03;
literature search of weight management (weight loss or
combined resistance and aerobic: SMD –0.67; 95% CI,
avoidance of weight gain) identified 171 systematic re-
–1.10 to –0.34), although findings for resistance exercise
views; one met eligibility criteria and was included in the
were no longer significant after excluding studies with fewer
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review.65
than 25 patients per arm (SMD –0.52; 95% CI, –1.21 to
Characteristics and results of included systematic reviews 0.17). Meta-analyses that focused on specific types of
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

are provided in the Data Supplement (online only). In cancer reported benefits in breast cancer treated with
addition, the searches identified 13 exercise RCTs,66-78 adjuvant chemotherapy and/or radiotherapy,26 colorectal
eight nutrition RCTs (11 publications),72,79-88 and two cancer treated with chemotherapy,39 lung cancer treated
weight management RCTs89,90 that were published after the with chemotherapy,48 prostate cancer treated with radiation
included systematic reviews. In the opinion of the Panel, therapy,31 and hematologic malignancies.10,17
these RCTs did not alter the conclusions drawn from the
systematic reviews. Cardiorespiratory fitness. Meta-analyses evaluating the
impact of exercise interventions on maximal or peak oxygen
Study Quality Assessment consumption (VO2max or VO2peak, respectively) consis-
The quality of included systematic reviews was assessed tently reported moderate to large benefits. A 2019 meta-
using the 11-item AMSTAR tool,91 with results provided in analysis evaluating the effect of aerobic exercise with or
the Data Supplement. Quality scores of reviews ranged without resistance exercise in patients receiving neoadjuvant
from 4 to 11. The quality of the individual studies included or adjuvant therapy for a mix of cancer types found that
in each review was variable, and there was heterogeneity in exercise led to a moderate improvement in VO2max (SMD
the interventions evaluated. Overall, the quality of evidence 0.46; 95% CI, 0.23 to 0.69; 12 studies, N 5 1,318 pa-
was higher for exercise interventions than for dietary in- tients).19 Similarly, a 2018 meta-analysis of aerobic and/or
terventions in this population. Very little evidence was resistance exercise during treatment in patients with a mix of
available to evaluate the effects of intentional weight loss or cancer types reported that individuals randomly assigned to
avoidance of weight gain during cancer treatment. exercise increased VO2 peak relative to control patients
(weighted mean difference [MD] 1.37 mL O2 3 kg–1 3 min–1;
RECOMMENDATIONS 95% CI, 0.58 to 2.16; 14 studies, N 5 980 patients).46 Meta-
Clinical Question 1 analyses that focused on specific cancer types reported
cardiorespiratory benefits of aerobic and/or resistance ex-
Does exercise during cancer treatment safely improve out- ercise in breast cancer treated with chemotherapy40; lung
comes related to QoL, treatment toxicity, or cancer control? cancer following surgery22; and prostate cancer treated with
Recommendation 1.1. Oncology providers should recom- androgen-deprivation therapy (ADT).38 Exercise also im-
mend aerobic and resistance exercise during active proved 6-Minute Walk Test (6MWT) scores among patients
treatment with curative intent to mitigate side effects of with non–small-cell lung cancer who took part in an exercise
cancer treatment (Type: evidence based, benefits outweigh intervention preoperatively45 or postoperatively,22 but did not
harms; Evidence quality: moderate to low; Strength of have a statistically significant effect among patients receiving
recommendation: strong). chemotherapy for lung cancer.34 Patients with hematologic
Note: Exercise interventions during active treatment reduce malignancies who took part in exercise interventions during
fatigue; preserve cardiorespiratory fitness, physical func- bone marrow transplantation also experienced increases in
tioning, and strength; and in some populations, improve 6MWT distances.17
QoL and reduce anxiety and depression. In addition, ex- Muscle strength. Meta-analyses evaluating the impact of
ercise interventions during treatment have low risk of ad- aerobic and/or resistance exercise on muscle strength in
verse events. Evidence was not sufficient to recommend for men with prostate cancer undergoing treatment with ADT

Journal of Clinical Oncology 2495

 Ligibel et al

demonstrate significant and consistent improvements in studies, N 5 730 patients) and anxiety (SMD 0.75; 95% CI,
upper-body and lower-body strength.24,38,55 Evidence re- 0.60 to 0.91; 10 studies, N 5 793 patients).49 Fewer studies
garding the impact of aerobic and/or resistance exercise on have addressed other cancer types, and the results were not
strength in other cancer types was less consistent, but im- significant in meta-analyses of patients with colorectal
provements in upper-body or lower-body strength were re- cancer,39 hematologic malignancies,10,17 or lung cancer.48
ported among patients with breast cancer,49 hematologic
Body composition. Among patients receiving ADT for
malignancies treated with bone marrow transplantation,17
prostate cancer, meta-analyses suggest that resistance
and lung cancer during chemotherapy48 or in the
exercise with or without aerobic exercise modestly reduces
preoperative48 or postoperative22 periods.
percent body fat (MD –1.0%; 95% CI, –1.3 to –0.6; 10
Physical function. Meta-analyses evaluating the impact of studies, N 5 603 patients)38 and fat mass (MD –0.6 kg;
aerobic and/or resistance exercise interventions during 95% CI, –0.8 to –0.3; 15 studies, N 5 917 patients),38
cancer treatment demonstrate small but statistically signif- without a significant effect on body mass index.18,38 Ex-
icant improvements in self-reported and objectively mea- ercise interventions also led to a statistically significant
sured physical function. Aerobic and/or resistance exercise increase in lean mass in some meta-analyses,18,38 but not in
led to small but statistically significant improvements in self- others.24 Aerobic and/or resistance exercise did not have a
reported physical function among patients with a mix of significant impact on body composition or weight in pa-
cancer types (SMD 0.22; 95% CI, 0.13 to 0.32; 25 exercise tients undergoing treatment for breast cancer (two trials,
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arms)50; breast cancer (SMD 0.14; 95% CI, 0.01 to 0.27; 10 N 5 324 patients),49 or in patients with hematologic ma-
studies, N 5 1,016 patients)32; and colorectal cancer (SMD lignancies (body weight: three studies, N 5 964; lean body
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

0.26; 95% CI, 0.04 to 0.48; five studies, N 5 330 patients).39 mass: three studies, N 5 290 patients).10
The results from a meta-analysis of patients with hematologic Sleep. A meta-analysis of two studies in breast cancer
malignancies were of a similar magnitude but not statistically (N 5 227 patients) reported a moderate reduction in sleep
significant (SMD 0.15; 95% CI, –0.01 to 0.32; eight trials, disturbance with exercise interventions during cancer
N 5 1,329 patients).10 Exercise interventions led to mixed treatment (SMD –0.47; 95% CI, –0.88 to –0.05).33 A trial of
results across a range of physical function tests, including 301 patients with breast cancer, reported in the systematic
6MWT and Sit to Stand tests, in men with prostate cancer review but not included in the meta-analysis, suggested
treated with ADT.18,38 that a higher dose of aerobic exercise during chemotherapy
Quality of life. The impact of exercise interventions on QoL may provide greater sleep benefits than a lower dose.92
varied across the included meta-analyses. Among patients
Cognitive function. A 2020 systematic review evaluated the
with a mix of cancer types, exercise led to a small QoL benefit
impact of exercise interventions on cognition in patients
(SMD 0.16; 95% CI, 0.08 to 0.23; 32 exercise arms).50 A
with early-stage cancer, with most of the included studies
small benefit was also reported among patients with colo-
evaluating cognition as a secondary outcome.21 Nine RCTs
rectal cancer who took part in exercise training during
evaluated aerobic and/or resistance exercise during
neoadjuvant, adjuvant, or palliative chemotherapy (SMD
treatment and assessed cognition using the European
0.22; 95% CI, 0.02 to 0.43; six studies, N 5 369 patients).39
Organization for Research and Treatment of Cancer QoL
A moderate benefit was reported in one meta-analysis of
Questionnaire-Core 30. A statistically significant benefit of
patients with breast cancer during treatment (SMD 0.43;
exercise was reported in three trials. The remaining studies
95% CI, 0.33 to 0.54; 16 studies, N 5 1,563 patients).49 A
reported no statistically significant difference between
second meta-analysis, focused on patients with breast cancer
arms. No meta-analysis was performed.
who were receiving adjuvant radiation therapy, reported a
numerically similar result that was not statistically significant Chemotherapy completion. Relatively little information is
(SMD 0.46; 95% CI, –0.01 to 0.93; seven studies, N 5 691 available on the impact of exercise interventions during cancer
patients).36 Among patients with hematologic malignancies, a treatment on chemotherapy completion or dose intensity. The
2019 Cochrane review found a nonsignificant impact of available evidence consists primarily of null results,20,23,39 al-
exercise on QoL (SMD 0.11; 95% CI, –0.03 to 0.24; eight though two breast cancer trials have reported benefits.93,94
studies, N 5 1,259 patients),10 whereas a 2021 review of Cancer control. Systematic reviews of patients with a mix of
patients treated with bone marrow transplantation reported a tumor types,23 hematologic malignancies,10 or advanced
significant improvement (MD 3.38 points; 95% CI, 0.37 to cancer51 have identified only a small number of RCTs that
6.39; 11 studies, N 5 624 patients).17 Two meta-analyses of assessed cancer outcomes such as recurrence or survival
patients with prostate cancer treated with radiation therapy31 in relation to exercise during cancer treatment. The results
or ADT54 reported no significant impact of exercise on QoL. were null, but most of the included studies were not
Depression and anxiety. In patients with breast cancer, meta- designed to assess survival outcomes.
analyses suggest that exercise during cancer treatment may Type and dose of exercise. The majority of meta-analyses
reduce both depression (SMD 0.67; 95% CI, 0.51 to 0.83; 10 included in this review combined data from a variety of

2496 © 2022 by American Society of Clinical Oncology Volume 40, Issue 22

 Diet, Physical Activity, and Weight Management

types, modes of administration, and schedules of exercise, with lung cancer, one focused specifically on non–small-
making it difficult to differentiate effects of aerobic versus cell lung cancer and the other on lung cancers more
resistance exercise or determine the best duration, broadly, preoperative exercise reduced postoperative
schedule, or intensity of exercise program during cancer length of hospital stay (SMD –0.58; 95% CI, –0.97 to –0.20;
treatment. As reported previously, meta-analyses demon- six studies, 513 patients45; MD –4.23 days; 95% CI, –6.14
strated significant improvements in fatigue as a result of to –2.32; five studies, N 5 231 patients35). Preoperative
aerobic and combined resistance and aerobic exercise exercise also reduced postoperative pulmonary compli-
interventions.29 Additionally, both supervised (SMD 0.32; cations (odds ratio [OR] 0.44; 95% CI, 0.27 to 0.71; six
95% CI, 0.12 to 0.52) and unsupervised (SMD 0.33; 95% studies, N 5 382 patients35; relative risk 0.50; 95% CI, 0.39
CI, 0.13 to 0.54) exercise interventions led to reductions in to 0.66; eight studies45) and reduced postoperative
fatigue.26 In terms of cardiorespiratory fitness, Bjørke et al19 pneumonia (OR 0.47; 95% CI, 0.24 to 0.95; six studies,
reported that improvements in VO2max in patients with a N 5 379 patients35) among patients with lung cancer. Both
mix of cancer types were greater with longer duration of meta-analyses had limitations: one included a non-
exercise sessions, longer weekly exercise durations, and randomized study,35 and the other included the same study
greater weekly exercise volumes. Additionally, a shorter twice when analyzing postoperative pulmonary complica-
overall intervention duration was associated with greater tions.45 Among patients undergoing abdominal surgery for
improvements in VO2max. Finally, one meta-analysis GI or genitourinary cancers, preoperative exercise did not
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looking at the effect of exercise on strength in men with significantly affect risk of postoperative overall or pulmonary
prostate cancer on ADT suggested a significant relationship complications, although one meta-analysis of six studies
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

between resistance exercise and changes in upper-body suggested a modest reduction in postoperative length of
strength,38 but other meta-analyses on this topic did not stay (MD –1.08 days; 95% CI, –2.29 to –0.14).25,52
stratify by exercise type. Thus, the current evidence does
not allow for the creation of specific dosing guidance for the Question 1: Clinical interpretation. Aerobic and resistance
duration or intensity of exercise during treatment required exercise during cancer treatment has numerous well-
to favorably affect outcomes. documented benefits for patients undergoing cancer treat-
ment with curative intent.12,46 Although the literature eval-
Adverse events. Reporting of adverse events is variable
uating the benefits of exercise in the setting of active cancer
across studies, reducing the certainty of the evidence. Nev-
treatment has evaluated different forms of exercise with
ertheless, the frequency of adverse events with exercise
different schedules, intensities, and means of administra-
during treatment appears to be low. In a meta-analysis of the
tion, the results consistently demonstrate that increasing
impact of exercise interventions on cardiorespiratory fitness,
exercise during treatment improves cardiorespiratory fitness
13 of 14 studies conducted in patients receiving cancer
and reduces symptoms such as fatigue. Studies have also
treatment provided information about adverse events.46
demonstrated few adverse events in patients taking part in
Eleven exercise-related adverse events were reported
exercise interventions during cancer treatment,46 although it
among 670 patients randomly assigned to an exercise arm:
acute myocardial infarction (n 5 1), syncope (n 5 1), hy- should be noted that a proportion of these trials used su-
potension (n 5 1), chest pain (n 5 1), dizziness (n 5 1), leg pervised exercise programs overseen by exercise profes-
pain (n 5 1), musculoskeletal adverse event (n 5 4), and sionals. These findings suggest that the incorporation of
tiredness (n 5 1). Low rates of adverse events and non- exercise during active treatment has clear benefits for pa-
reporting of adverse events by some studies were also noted in tients with cancer, and oncology providers should include
other systematic reviews.17,18,22,38 Meta-analyses of seri- assessment of exercise behaviors and recommendations to
ous or grade 3-5 adverse events in relation to exercise exercise as a part of oncology visits.
were not statistically significant, but certainty of evidence Although the data are more limited, exercise interventions
tended to be very low.10,48,49 also appear to have benefits when implemented before
surgery for lung cancer, a procedure associated with sig-
Recommendation 1.2. Oncology providers may recom-
nificant morbidity and mortality.35,45 Preoperative exercise
mend preoperative exercise for patients undergoing sur-
may also provide benefits in other malignancies, but evi-
gery for lung cancer to reduce length of hospital stay and
dence is currently weaker than for lung cancer.25,52 Pre-
postoperative complications (Type: evidence based, ben-
habilitation is still an emerging field, and additional RCTs
efits outweigh harms; Evidence quality: low; Strength of
recommendation: weak). are warranted. Given the benefits of exercise in patients
with cancer, several guidelines recommend exercise for
patients and survivors.9,11,12
Literature review and analysis. Meta-analyses have eval-
uated the effects of preoperative exercise on postoperative Despite these recommendations, many patients are inac-
complications and other outcomes among patients un- tive during cancer treatment. A recent ASCO survey of
dergoing surgery for lung cancer35,45 or for GI or genito- 2,419 patients with cancer, 48% of whom were currently
urinary cancers.25,52 In two 2019 meta-analyses of patients receiving treatment at the time of survey completion, found

Journal of Clinical Oncology 2497

 Ligibel et al

that 25% of survey respondents were not engaging in any A 2019 meta-analysis broadly evaluated the impact of
regular exercise and another 25% engaged in suboptimal dietary interventions on patient-reported outcomes. The
levels of exercise.95 Notably, individuals whose oncology analysis included 15 trials and 1,290 patients, although trial
providers discussed the importance of exercise or a healthy populations included patients both during and after cancer
diet as a part of cancer care reported a greater likelihood of treatment and dietary interventions were varied, including
making changes in lifestyle behaviors after cancer diag- plant-based diets, weight loss diets, and healthy diets.56
nosis, and another recent study in individuals with colon There was no effect of most dietary interventions in ag-
cancer in the United Kingdom found that patients who gregate on fatigue (SMD 0.18; 95% CI, –0.02 to 0.39) or
reported that their oncology providers addressed exercise QoL (SMD 0.07; 95% CI, –0.10 to 0.24), but potentially an
during oncology visits were more likely to engage in physical effect of a plant-based dietary pattern on fatigue (SMD
activity (51% in the advice group v 42% in the no advice 0.62; 95% CI, 0.10 to 1.15). In another analysis evaluating
group; OR 1.74; 95% CI, 1.60 to 1.90; P , .001), and more a broad range of dietary interventions on patient-reported
likely to meet physical activity guidelines (25% v 20%; OR outcomes, a Cochrane review evaluated the impact of di-
1.70; 95% CI, 1.54 to 1.88; P , .001).96 This work etary interventions during pelvic radiotherapy on GI
highlights the importance of oncology provider engagement symptoms. Low-certainty evidence, on the basis of small
in encouraging regular physical activity in their patients numbers of patients, suggested that protein supplements,
receiving cancer treatment. dietary counseling, and probiotics may reduce the risk of
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Notably, the appropriate referral for exercise in patients acute, grade 2 or worse diarrhea.60 Also, with low certainty
undergoing treatment for cancer may depend on several of evidence, one study in 108 patients showed that a high-
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

factors, such as comorbidities, treatment toxicities, and the fiber diet led to improvements in GI symptoms and QoL at
patient’s physical activity level. Many patients can safely one year postradiotherapy.99 Significant work remains to be
perform unsupervised exercise, whereas others may need done, as detailed in the research gaps section below.
supervised cancer-specific exercise, clinically supervised
Recommendation 2.2. Neutropenic diets (specifically diets
exercise, or to participate in a cancer rehabilitation program
that exclude raw fruits and vegetables) are not recom-
before undertaking exercise on their own. National efforts
mended to prevent infection in patients with cancer during
are focusing on building algorithms and decision-support
active treatment (Type: evidence based, harms likely to
tools to point to the most safe, feasible, and effective in-
outweigh benefits; Evidence quality: low; Strength of rec-
tervention for a given patient.97,98
ommendation: weak).
Clinical Question 2
Does consuming a particular dietary pattern or food(s) Literature review and analysis. There is no standard
during cancer treatment safely improve outcomes related to definition of a neutropenic diet. Diets included in this
QoL, treatment toxicity, or cancer control? review focused on food safety practices that were more
restrictive than those endorsed by the US Food and Drug
Recommendation 2.1. There is currently insufficient evi-
Administration100 or the Centers for Disease Control and
dence to recommend for or against dietary interventions
Prevention101 for the general population and/or recom-
such as ketogenic or low-carbohydrate diets, low-fat diets,
mended the avoidance of foods such as raw fruits and
functional foods, or fasting to improve outcomes related to
vegetables with the intent of decreasing exposure to
QoL, treatment toxicity, or cancer control.
microbes and bacteria. Three systematic reviews of
Literature review and analysis. Systematic reviews have neutropenic diets were included in the current
evaluated a broad range of dietary interventions in patients review57,61,63 In a meta-analysis that included studies of
during cancer treatment, including changes in timing of children and adults, infection was noted in 53.7% of the
food intake (eg, intermittent fasting), dietary patterns, patients randomly assigned to a neutropenic diet and
macronutrient composition (eg, low-fat or low-carbohydrate 50.0% of the patients assigned to an unrestricted diet
diets), and intake or omission of particular foods.56,58-60,62,64 (relative risk 1.13; 95% CI, 0.98 to 1.30; five studies, 388
The majority of randomized trials conducted in patients patients).57 Of the three RCTs conducted in adults, only
undergoing active treatment have focused on patient- one enrolled more than 50 patients: Gardner et al en-
reported outcomes or on biomarkers (see the section on rolled 153 patients (age range, 17-88 years) who were
biomarkers in discussion), with little or no information re- receiving induction chemotherapy for acute myeloid
garding the impact of dietary change during treatment on leukemia.102 Patients were randomly assigned to a diet
cancer outcomes. Additionally, most of these trials have containing no raw fruits or vegetables (cooked diet) or to
been small, enrolling fewer than 100 patients, often with a diet containing fresh fruit and fresh vegetables (raw
different cancer types and stages. The results have gen- diet). A major infection occurred in 29% of patients in the
erally failed to show consistent effects of dietary change cooked arms and 35% of patients in the raw arm (P 5
during treatment on patient-reported or other outcomes in .60). There was no significant difference in survival
patients with cancer.56,58-60 between the two arms (P 5 .36).

2498 © 2022 by American Society of Clinical Oncology Volume 40, Issue 22

 Diet, Physical Activity, and Weight Management

Question 2: Clinical interpretation. Although interest in Recommendation 3. There is currently insufficient evi-
dietary modification for the purpose of improving cancer dence to recommend for or against intentional weight loss
outcomes or reducing treatment toxicity remains high,103-105 or prevention of weight gain interventions during active
there are very few data at this time to support specific dietary treatment to improve outcomes related to QoL, treatment
modifications or foods as a part of cancer treatment. toxicity, or cancer control.
Neutropenic diets, generally defined as diets that seek to
reduce bacterial exposure by limiting raw fruits and vege- Literature review and analysis. There have been few RCTs
tables, have long been recommended to prevent infection in of weight management interventions during cancer
patients with hematologic malignancies, and especially in treatment.18,38,65 Most of the studies conducted to date
individuals who have undergone bone marrow transplant. have had small samples sizes and have had weight loss as
Although the available literature is somewhat limited, with the primary end point, providing information regarding
many studies having small samples sizes or lack of ran- feasibility, but making it difficult to determine the effect of
domized design, data do not support the use of neutropenic weight loss on patient-reported or other outcomes in pa-
diets to lower infection risk in this patient population. Given tients receiving cancer treatment. A 2017 systematic review
that these diets are also less palatable to patients and may evaluated the efficacy of behaviorally based dietary inter-
limit important nutrients and bioactive compounds,57 the ventions, with or without physical activity, for avoidance of
ASCO Expert Panel generally felt that the harms outweigh weight gain among women receiving chemotherapy for
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potential benefits, especially given that data currently breast cancer.65 Of the four included RCTs, two of five
suggest no difference in infection risk in individuals ran- weight loss arms resulted in lower body weight at study
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

domly assigned to neutropenic diets (however defined in completion compared with usual care control arms. A
the individual studies) and unrestricted diets. number of weight loss intervention trials have also been
conducted in men with prostate cancer, but study het-
It was not possible to make other recommendations re-
erogeneity makes it difficult to draw conclusions from this
garding diet during cancer treatment on the basis of
literature.18,38 Exercise-only interventions have not dem-
the available literature. There are exceedingly few RCTs
onstrated significant weight loss in this population. These
testing the effect of specific diets, eating patterns, or foods
somewhat limited findings suggest that weight manage-
during cancer treatment on cancer or patient-reported
ment interventions may be possible during cancer treat-
outcomes.60,62,64 The heterogeneity of the RCTs that
ment, but evidence regarding the risks and benefits of on-
have been conducted and the limited number of rigorously
treatment weight management remain uncertain.
designed studies with robust sample sizes make it difficult
to develop recommendations on the basis of this literature. Question 3: Clinical interpretation. The limited evidence
The limited data currently available do not support a benefit available does suggest intentional weight loss is feasible
of dietary modification during treatment on fatigue, QoL, during cancer treatment, at least in individuals undergoing
or other patient-reported outcomes. On the basis of the treatment for breast and possibly prostate cancers, but
early-stage nature of trials evaluating diets and dietary there is little evidence at this time that purposeful weight
patterns associated with lower cancer risk in observational loss provides significant benefit to patients during active
and/or preclinical studies—including ketogenic or low- treatment. Given the abundant data from observational
carbohydrate diets, intermittent fasting, or the consump- studies suggesting a relationship between excess adiposity
tion of functional foods such as green tea or soy—it is not and increased risk of developing and dying from cancer,1-6
possible to determine whether these diets offer any benefit there is a critical need for more research in this area.
to patients with cancer. It is also notable that studies have
suggested that patients randomly assigned to ketogenic DISCUSSION
diets express lower levels of dietary satisfaction compared The overarching goal of this guideline is to provide evidence-
with patients randomly assigned to control or other dietary based recommendations to guide lifestyle changes in pa-
interventions.64 Finally, despite the significant observa- tients undergoing treatment for cancer. This guideline is the
tional data showing an association between a healthy or first to focus specifically on this portion of the cancer care
prudent diet and lower cancer risk and/or better outcomes trajectory. This guideline was also developed for oncology
in several malignancies,3 there are very limited data testing professionals, with the intent of providing evidence-based
the impact of plant-based diet interventions during active recommendations for optimizing treatment tolerance, QoL,
treatment on toxicity or cancer outcomes, highlighting a and cancer control in patients undergoing treatment.
critical need for further research in this area.
Our review of the evidence, including 42 systematic reviews
Clinical Question 3 and several additional RCTs, showed that exercise inter-
Do interventions to promote intentional weight loss or ventions led to significant and clinically important benefits
avoidance of weight gain during cancer treatment safely for patients with cancer being treated with systemic therapy,
improve outcomes related to QoL, treatment toxicity, or radiation, and/or surgery. Exercise led to improvements in
cancer control? cardiorespiratory fitness and physical function, both of

Journal of Clinical Oncology 2499

 Ligibel et al

which are negatively affected by cancer treatment and are guidelines, evidence regarding the long-term impact of
related to both development of comorbidities and decline in exercise, diet, and weight management interventions
functional status. Exercise also mitigated other toxicities of during active treatment was limited. Although ongoing work
cancer treatment, including fatigue and mood disorders. will fill in some of these gaps over the next decade, the
Finally, exercise helped to preserve strength, especially in limited research in this area made it challenging to develop
men with prostate cancer currently undergoing treatment comprehensive guidance for patients undergoing cancer
with ADT. These findings suggest that the incorporation of treatment.
exercise can improve treatment tolerability and enhance It should be noted, however, that the lack of guidance in
fitness and functional status in patients undergoing treat- these areas should not be interpreted as a statement that
ment. On the basis of this evidence, exercise should be dietary change and weight management have no value in
incorporated as a standard part of oncology treatment. patients during or after cancer treatment. The Panel ex-
Like several other guidelines, including the American pressly did not want to convey the impression that these
College of Sports Medicine (ACSM) Roundtable Report,12 recommendations either be considered a tacit endorse-
the National Comprehensive Cancer Network Survivorship ment of diets high in processed and red meat, processed
Guidelines,106 and the American Cancer Society Nutrition foods, or refined carbohydrates or suggest that weight
and Physical Activity Guidelines for Cancer Survivors,11 this management is not important for overall health, given the
guideline recommends that patients with cancer engage in high prevalence of obesity among cancer survivors and the
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aerobic and resistance exercise. Our review of the literature known adverse health consequences of excess adiposity.
of the impact of exercise interventions during cancer The literature suggests that a cancer diagnosis is a
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

treatment also resulted in a similar list of benefits as the teachable moment, in which patients look to make changes
ACSM Roundtable Report, although the ACSM report in- in behavior to improve long-term outcomes. A recent ASCO
cluded both patients currently receiving treatment and survey of 2,419 oncology patients in the United States
post-treatment survivors.12 found that almost 75% of patients reported making
As noted before, this guideline focused only on the on- changes in their diet or exercise patterns after cancer di-
treatment period, and thus, included only a subset of the agnosis in an effort to improve outcomes.95 The importance
evidence used to shape other guidelines. In addition, the of regular exercise, maintaining weight in a healthy range,
guideline Panel exclusively considered data from RCTs in and consuming a high-quality diet have well-established
humans as the basis for its recommendations. This ap- value in decreasing risk of cardiovascular disease, meta-
proach differs somewhat from some other guidelines on this bolic disorders, and other chronic illnesses. Improving
topic but was adopted to provide direct evidence for the lifestyle behaviors earlier in the cancer care continuum
oncology clinician and patient of the expected impact of could have longer-term benefits for patients, which are not
making a change in diet, exercise, or weight during cancer reflected in the current literature. Our goal was to highlight
treatment. Although observational data of lifestyle factors the areas in which there is consistent and convincing ev-
and cancer risk and outcomes have played an important idence that lifestyle change provides benefits for patients
role in identifying critical relationships between diet, ex- undergoing cancer treatment and underscore the need for
ercise, weight, and cancer, healthy lifestyle behaviors are more research in areas where evidence is currently in-
generally related to each other and to other so-called sufficient to provide concrete recommendations, in hopes
healthy person attributes, such as avoiding tobacco that future guidelines will provide a more comprehensive
products, compliance with screening guidelines, higher blueprint to improve short-term and longer-term outcomes
socioeconomic status, better preventative care, etc. Data in patients undergoing cancer therapy.
from RCTs are thus critical to avoid these healthy person
biases and establish the expected benefits of lifestyle SPECIAL CONSIDERATIONS
changes after cancer diagnosis on cancer recurrence, Exercise in Individuals Living With Advanced Cancers
functional status, patient-reported outcomes, and other The literature evaluating the feasibility, safety, and potential
end points important to patients and clinicians. benefits of exercise in patients with advanced cancer is
As the Expert Panel reviewed the evidence from random- relatively limited. A few systematic reviews have summa-
ized trials of lifestyle interventions during cancer treatment, rized this literature and have largely reported mixed
it became apparent that there were significant gaps in this results—either null or showing a modest benefit of
literature, in particular regarding the impact of exercise, exercise—in relation to outcomes such as QoL and physical
dietary change, or weight loss on outcomes such as cancer function.28,42,44,53,107 A 2021 systematic review evaluated
recurrence and mortality. In the case of dietary or weight the safety and potential benefits of exercise interventions in
management interventions, there was little information from patients with bone metastases.53,108 Seventeen RCTs, in-
RCTs even regarding the impact of these interventions on cluding a mix of patients with and without bone metastases,
functional or patient-reported outcomes. Additionally, given were included. Some of the individual studies reported
the design of the majority of the RCTs used to inform these benefits in outcomes such as physical function. Serious

2500 © 2022 by American Society of Clinical Oncology Volume 40, Issue 22

 Diet, Physical Activity, and Weight Management

adverse events were rare, even in patients with bone adiponectin), sex hormones (eg, estradiol, testosterone,
metastases. Another meta-analysis involving small num- and sex hormone–binding globulin), immune function (eg,
bers of patients with advanced lung cancer (sample sizes CD-4 cells), and inflammatory markers (eg, c-reactive
ranging from 59 to 121 patients) reported an improvement protein, tumor necrosis factor-a, and interleukin 6). In
in the 6MWT and disease-specific global health-related general, exercise appears to favorably influence insulin-like
QoL with exercise.44 The results for dyspnea, the physi- growth factor-I and II, CD-4 cells, and c-reactive protein,8
cal function component of health-related QoL, and fatigue whereas calorically restricted diets reduce leptin (and
were not statistically significant. Finally, one systematic triglycerides—more related to subsequent cardiovascular
review focused specifically on exercise in relation to survival disease)114—mixed effects are noted with other circulating
in individuals with advanced cancer.51 None of the six biomarkers.8,114 However, almost all of these studies have
included RCTs reported a statistically significant impact of been performed in longer-term cancer survivors who have
exercise on survival, and a meta-analysis of four of the trials long completed therapy, and the effects among patients
also produced a nonsignificant result. However, duration of actively undergoing treatment is unknown. Given that
the exercise intervention was brief (6-12 weeks), the various forms of treatment are likely to exacerbate in-
population was heterogeneous, and survival was an ex- flammation and suppress immunity, the generalizability of
ploratory outcome. This literature in aggregate provides current data to patients currently undergoing treatment is
preliminary support for the safety of exercise in the setting of questionable. Moreover, the search for an ideal biomarker
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advanced cancer,27 but more work is needed to define its that is influenced by these lifestyle factors but at the same
benefits in this population. time is closely linked with cancer outcomes is a continual
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

work in progress. Studies such as the Men’s Eating and

Exercise, Diet, Weight Management, and Living Study (CALGB 70807 [Alliance]) in which prostate-
Health Disparities specific antigen doubling time or tumor upgrading on the
Although ASCO clinical practice guidelines represent ex- basis of tumor volume or grade serve as useful models that
pert recommendations on the best practices in disease can inform future studies within the patient population.115
management to provide the highest level of cancer care,
many patients have limited access to medical care or re- RESEARCH GAPS AND FUTURE DIRECTIONS
ceive fragmented care. Factors such as race and ethnicity,
Our review of the published literature demonstrates a
age, socioeconomic status, sexual orientation and gender
profound gap in quality research focusing upon defining
identity, geographic location, and insurance access are
optimal diet, weight management, and to a somewhat
known to affect cancer care outcomes, as well as diet and
lesser degree, exercise strategies to maximize therapeutic
exercise behavior.109 Racially and/or ethnically diverse
responses and the reduction in both acute and long-term
patients with cancer suffer disproportionately from
toxicity. Unfortunately, the shallow evidence base limited
comorbidities, experience more substantial obstacles to
the recommendations this Panel could make, especially for
receiving timely care, are more likely to be uninsured, and
diet and weight management. There is a critical need for
are at greater risk of receiving fragmented care or poor-
greater investment in clinical research in this area. Out-
quality care than other Americans.110-112 In addition, the
comes of interest are diverse. Improving efficacy of therapy
very factors that are related to cancer disparities also affect
and reducing toxicity are of foremost interest and potential
patients’ ability to achieve adequate levels of exercise, eat a
impact. Data regarding maintenance of optimal treatment
plant-based diet (with lower amounts of refined grains,
intensity, such as limiting dose reductions and delays in
sugars, and red and processed meats), and achieve and
therapy, are relevant to improved outcomes. In addition,
maintain a healthful weight. Social determinants of health
patient-reported outcomes related to treatment tolerance,
that are governed by a residential zip code often dictate the
comorbidity risk, prognostic biomarkers, and QoL, including
availability of safe places to exercise, large grocery stores
physical performance, fatigue, and psychosocial issues, are
that offer a variety of fresh, healthful, and affordable foods,
relevant study outcomes. Studies should address the po-
and the food security that frees patients to pursue calorie
tential of lifestyle interventions to reduce the cost of care by
restriction without the worry of knowing whether there will
lowering the frequency of emergency department visits,
be a next meal or not.113 Sociodemographic factors such as
hospitalizations, or readmissions, as well as reduction in
age, race, and education further compound these dis-
costs associated with therapy-related chronic toxicities.
parities and accentuate the need for social workers and
adequate social support. Although RCTs testing the impact of exercise, diet, and
weight management interventions during treatment on
Biomarker End Points outcomes of interest will provide the strongest evidence to
Various surrogate end points have been explored in exer- support the incorporation into cancer care, integration and
cise and dietary interventions, and largely include those embedding nutritional status and dietary assessment and
involved in glucose homeostasis and energy balance (eg, monitoring into clinical trials of novel cancer therapeutics,
glucose, insulin, insulin-like growth factors, leptin, and particularly large phase III trials, would provide important

Journal of Clinical Oncology 2501

 Ligibel et al

hypothesis-generating information to direct the develop- rigorously using sufficient sample sizes and methods that
ment of RCTs. decrease the risk of bias, reduce confounding, and improve
the quality of the research and certainty of the evidence to
Many opportunities exist at modest overall cost, to integrate
strengthen future guidelines.
validated and novel assessment tools of diet, nutritional
status, and exercise into clinical trials, such as body
composition assessment including fat distribution and lean GUIDELINE IMPLEMENTATION
muscle mass, use of enhanced statistical tools to analyze This guideline represents an important step in providing
dietary patterns, use of wearables to capture physical ac- guidance for adult patients regarding exercise, diet, and
tivity, and validated fitness tests such as the 6MWT. weight management during cancer treatment. Although the
Technological advances providing new tools for biosensing lack of evidence base, especially for diet and weight
of metabolic state and monitoring of physical activity, as management, limited the number of recommendations
well as the remarkable progress in metabolomics and ultimately made, the Panel recommended the incorpora-
lipidomics of biospecimens, will enhance the quality of tion of exercise into cancer treatment for patients receiving
future studies. systemic therapy and radiotherapy, as well as potentially in
Ultimately, a significant investment in phase I, II, and the preoperative setting for patients with lung cancer.
randomized phase III interventions trials of diet, exercise, Facilitating implementation of these recommendations for
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weight management interventions, or their combinations, exercise during cancer treatment will require addressing
during cancer treatment protocols with sufficient power and barriers to this care that exist at the patient, clinician, health
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

innovative designs will be needed for defining standards of system, and policy levels. For example, although patients
care. Such efforts in diet and exercise will require new report high interest in exercise,116 in order for this to be
initiatives from government and philanthropic sources, as successfully incorporated into patient care, patient-level
unlike the pharmaceutical industry that provides enormous barriers, including toxicities of cancer treatment; comor-
investment in cancer clinical trials, the options for sub- bidities; concerns about falls, injuries, or appearance while
stantial industry support for diet and fitness trials is very exercising; financial issues (lack of affordable programs);
modest. Large RCTs in diet and exercise with sufficient lack of access to programs; lack of time or social support;
statistical power to provide results on critical outcomes and limited guidance by clinicians, must be addressed.116,117
such as survival that will define care standards warrant the
Overcoming these barriers will require a systematic, multi-
same investment as novel therapeutics.
faceted approach involving the clinician, health care system,
Additionally, host genetics and tumor genomics is in- and overarching health care policies. Example clinician-level
creasingly directing cancer therapeutics and will contribute strategies include training on how to address these issues
to precision nutrition and exercise efforts in the oncology with patients118 and incorporating exercise or cancer re-
setting. In parallel, the field of nutrigenomics is emerging as habilitation clinicians and behavior change experts in the
the study of how genetic variation affects host responses to multidisciplinary oncology treatment team.119 Health care
dietary patterns, nutrients, and bioactives in the foods, and system strategies must focus on improving patient-provider
potentially contributes to individual responses to specific communication about these interventions and building re-
cancer therapeutics. The National Institutes of Health has ferrals for programs in multiple settings close to patients’
prioritized the theme of Nutrition for Precision Health with homes or via telemedicine, at varied hours or self-directed,
the goal of translation to clinical care allowing for more and including low- or no-cost options120 through partner-
personalized and individual guidance. Such a strategy is ships with community programs and organizations.121
very relevant to management of individuals undergoing Needed policy changes include insurance reimbursement
cancer therapy. for support of exercise during cancer treatment and the care
Future research must incorporate more diverse patient coordination necessary to integrate this with the rest of the
samples. Studies are needed in patients with cancers other patient’s care. Accreditation standards or quality metrics that
than breast, prostate, lung, and colorectal, which were the include exercise as a standard component of cancer care
most commonly studied cancers, and in patients on immu- would drive practice change, allowing greater adoption of the
notherapies or those with metastatic disease. Studies need to recommendations of this and other guidelines focused on
test interventions in sociodemographically diverse samples, these topics in patients with cancer.
especially those who are medically vulnerable, and should
have careful attention to eligibility criteria or allow for stratifi- PATIENT AND CLINICIAN COMMUNICATION
cation of results.
Communication between patients and clinicians will be a
In summary, a commitment to studies that provide high- critical aspect in ensuring implementation of these
quality evidence is imperative. The quality of many studies guideline recommendations. Some patients may be un-
we reviewed was low, which contributed to the weak rec- aware of the impact of exercise during treatment on patient
ommendations. Future research must be conducted outcomes, whereas others may pursue exercise and diet

2502 © 2022 by American Society of Clinical Oncology Volume 40, Issue 22

 Diet, Physical Activity, and Weight Management

changes that are not supported by evidence. The goal of the agreed with slight modifications ranged from 88% to 98%.
clinician should be to introduce the importance of exercise In addition, the full draft guideline was submitted to three
during cancer treatment and to make appropriate referrals external reviewers with content expertise. Expert Panel
fostering healthy lifestyle behaviors in patients undergoing members reviewed comments from all sources and de-
therapy, as behavior change not only requires the sharing of termined whether to maintain original draft recommen-
knowledge between clinicians and patients, but also the dations, revise with minor language changes, or consider
incorporation of motivational strategies, identification of major recommendation revisions. All changes were in-
barriers, and creative approaches to identification of and corporated before Evidence Based Medicine Committee
payment for resources to support behavior change. In a review and approval.
recent ASCO membership survey, 84% of oncologists118 ASCO believes that cancer clinical trials are vital to inform
report that although they recognize the benefits of diet, medical decisions and improve cancer care, and that all
exercise, and weight management, they feel that another patients should have the opportunity to participate.
team member should be delivering the interventions. Thus,
the overall goal of implementation of this guideline should
be to support clinicians in educating their patients about ADDITIONAL RESOURCES
the importance of exercise as a part of cancer care and to More information, including a supplement with additional
encourage them to use appropriate resources (oncology evidence tables, slide sets, and clinical tools and resources,
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rehabilitation, cancer certified fitness professionals, etc) to is available at [Link]/supportive-care-guidelines.

help their patients achieve these goals. Patient information is available at [Link].
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

EXTERNAL REVIEW AND OPEN COMMENT

The draft recommendations were released to the public for RELATED ASCO GUIDELINES
open comment from January 12, 2022, through January • Integration of Palliative Care into Standard On-
26, 2022. Response categories of “Agree as written,” cology Care122 ([Link]
“Agree with suggested modifications” and “Disagree. See JCO.2016.70.1474)
comments” were captured for every proposed recom- • Patient-Clinician Communication123 (http://
mendation with 61 responses received. Across recom- [Link]/doi/10.1200/JCO.2017.75.2311)
mendations, the proportion of respondents who agreed or

AFFILIATIONS EQUAL CONTRIBUTION

1
Dana-Farber Cancer Institute, Boston, MA J.A.L. and C.M.A. were expert panel cochairs.
2
American Society of Clinical Oncology, Alexandria, VA
3
University Medical Center Utrecht, Utrecht University, Utrecht, the AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF
Netherlands
4 INTEREST
The Ohio State University, Columbus, OH
5 Disclosures provided by the authors are available with this article at DOI
University of Alabama at Birmingham, Birmingham, AL
6 [Link]
University of Texas MD Anderson Cancer Center, Houston, TX
7
Yale School of Public Health, New Haven, CT
8
Patient Representative, Arlington, VA AUTHOR CONTRIBUTIONS
9
Cancer Wellness for Life, Lenexa, KS Conception and design: Jennifer A. Ligibel, Kari Bohlke, Anne M. May,
10
Ivy Rehab Network, White Plains, NY Steven K. Clinton, Wendy Demark-Wahnefried, Michele Late, Timothy F.
11
University of Arizona, Tucson, AZ Marshall, Cynthia A. Thomson, William A. Wood, Catherine M. Alfano
12
UNC School of Medicine, Chapel Hill, NC Administrative support: Kari Bohlke
13
Northwell Health Cancer Institute and Feinstein Institutes for Medical Collection and assembly of data: Jennifer A. Ligibel, Kari Bohlke,
Research, New York, NY Catherine M. Alfano
Data analysis and interpretation: Jennifer A. Ligibel, Kari Bohlke, Anne M.
May, Steven K. Clinton, Wendy Demark-Wahnefried, Susan C. Gilchrist,
CORRESPONDING AUTHOR
Melinda L. Irwin, Sami Mansfield, Timothy F. Marshall, Jeffrey A.
American Society of Clinical Oncology, 2318 Mill Rd, Suite 800,
Meyerhardt, Cynthia A. Thomson, William A. Wood, Catherine M. Alfano
Alexandria, VA 22314; e-mail: guidelines@[Link].
Manuscript writing: All authors
Final approval of manuscript: All authors
EDITOR’S NOTE Accountable for all aspects of the work: All authors
This ASCO Clinical Practice Guideline provides recommendations, with
comprehensive review and analyses of the relevant literature for each ACKNOWLEDGMENT
recommendation. Additional information, including a supplement with The Expert Panel wishes to thank Drs Dawn Hershman, Kerri Winters-
additional evidence tables, slide sets, clinical tools and resources, and Stone, Karen Basen-Engquist, Lisa Law, and Alicia Morgans, and the
links to patient information at [Link], is available at Evidence Based Medicine Committee for their thoughtful reviews and
[Link]/supportive-care-guidelines. insightful comments on this guideline.

Journal of Clinical Oncology 2503

 Ligibel et al

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n n n

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AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Exercise, Diet, and Weight Management During Cancer Treatment: ASCO Guideline
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted.
Relationships are self-held unless noted. I 5 Immediate Family Member, Inst 5 My Institution. Relationships may not relate to the subject matter of this manuscript.
For more information about ASCO’s conflict of interest policy, please refer to [Link]/rwc or [Link]/jco/authors/author-center.
Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

Steven K. Clinton Jeffrey A. Meyerhardt

Research Funding: NIH, American Institute for Cancer Research, American Honoraria: Cota Healthcare, Merck
Cancer Society, Department of Defense-Prostate Cancer Research Program, US Research Funding: Boston Biomedical (Inst)
Department of Agriculture, and The National Cattleman’s Beef Association
William A. Wood
Susan C. Gilchrist Stock and Other Ownership Interests: Koneksa Health, Elektra Labs
Employment: LabCorp Consulting or Advisory Role: Koneksa Health, Best Doctors Inc, Elektra Labs
Research Funding: Pfizer (Inst), Genentech (Inst)
Michele Late
Employment: Tenet Healthcare (I) No other potential conflicts of interest were reported.
Timothy F. Marshall
Employment: Ivy Rehab Network, Select Medical
Consulting or Advisory Role: Select Medical
Downloaded from [Link] by [Link] on June 30, 2024 from [Link]
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

© 2022 by American Society of Clinical Oncology Volume 40, Issue 22

 Diet, Physical Activity, and Weight Management

APPENDIX

TABLE A1. Recommendation Rating Definitions

Term Definitions
Quality of evidence
High We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the
effect, but there is a possibility that it is substantially different.
Low Our confidence in the effect estimate is limited: the true effect may be substantially different from the
estimate of the effect.
Very low We have very little confidence in the effect estimate: the true effect is likely to be substantially different from
the estimate of effect.
Strength of recommendation
Strong In recommendations for an intervention, the desirable effects of an intervention outweigh its undesirable
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effects.
In recommendations against an intervention, the undesirable effects of an intervention outweigh its
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

desirable effects.
All or almost all informed people would make the recommended choice for or against an intervention.
Weak In recommendations for an intervention, the desirable effects probably outweigh the undesirable effects,
but appreciable uncertainty exists.
In recommendations against an intervention, the undesirable effects probably outweigh the desirable
effects, but appreciable uncertainty exists.
Most informed people would choose the recommended course of action, but a substantial number would
not.

Journal of Clinical Oncology

 Ligibel et al

TABLE A2. Exercise, Diet, and Weight Management During Cancer Treatment Guideline Expert Panel Membership
Name Affiliation Role or Area of Expertise
Jennifer A. Ligibel, MD, cochair Dana-Farber Cancer Institute, Boston, MA Medical oncology, breast cancer, and
exercise and weight management
interventions
Catherine M. Alfano, PhD, cochair Northwell Health Cancer Institute and Behavioral science, symptom
Feinstein Institutes for Medical Research, management, and cancer care delivery
New York, NY research
Steven K. Clinton, MD, PhD The Ohio State University, Columbus, OH Prostate cancer, molecular carcinogenesis,
and chemoprevention
Wendy Demark-Wahnefried, PhD, RD University of Alabama at Birmingham, Diet and weight management in
Birmingham, AL obesity-related cancers
Susan C. Gilchrist, MD, MSa University of Texas MD Anderson Cancer Cardiorespiratory fitness and cancer
Center, Houston, TX
Melinda L. Irwin, PhD, MPH Yale School of Public Health, New Haven, Exercise and weight management trials in
CT breast and ovarian cancer
Michele Late Arlington, VA Patient representative
Downloaded from [Link] by [Link] on June 30, 2024 from [Link]

Sami Mansfield, BA Cancer Wellness for Life, Lenexa, KS PGIN representative

Timothy F. Marshall, PhD, MS Ivy Rehab Network, White Plains, NY Clinical exercise, rehabilitation, and cancer
Copyright © 2024 American Society of Clinical Oncology. All rights reserved.

Anne M. May, PhD University Medical Center Utrecht, Utrecht, Epidemiology, lifestyle interventions, and
the Netherlands cancer
Jeffrey A. Meyerhardt, MD, MPH Dana Farber Cancer Institute, Boston, MA GI cancer, lifestyle interventions, and
cancer
Cynthia A. Thomson, PhD, RD University of Arizona, Tucson, AZ Diet and cancer care
William A. Wood, MD, MPH UNC School of Medicine, Chapel Hill, NC Malignant hematology, stem-cell transplant,
outcomes research, and exercise
interventions
Kari Bohlke, ScD American Society of Clinical Oncology, ASCO Practice Guideline Staff (Health
Alexandria, VA Research Methods)
a
Panel member through December 2021.

© 2022 by American Society of Clinical Oncology Volume 40, Issue 22