When is the best time to start exercise after a cancer diagnosis? A modified Delphi consensus study of expert health professionals

When is the best time to start exercise after a cancer diagnosis? 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A modified Delphi consensus study of expert health professionals Germaine A Tan, Casey L Peiris, Nicholas F Taylor, Katherine E Harding, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8846045/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Purpose Exercise has benefits before, during and after cancer treatment. However, the optimal timing of when to start exercise remains unclear. This study aimed to establish expert consensus on the optimal timing for starting exercise following a cancer diagnosis. Methods This modified Delphi study followed Conducting and Reporting Delphi Studies guidelines to establish expert consensus. A steering committee of oncology clinicians, researchers and people with cancer developed initial survey statements addressing disease-, treatment-, person- and health service-related factors that may influence exercise initiation. A three-round modified electronic Delphi process was conducted to 1) collect expert opinions, 2) analyse emerging themes, and 3) refine statements for ranking on a 9-point Likert scale (1 = Strongly Disagree to 9 = Strongly Agree). Statements achieving ≥ 80% consensus were retained. Results Eighty oncology experts from five continents participated in Round 1, with retention rates of 80% and 77% in Rounds 2 and 3, respectively. By Round 3, consensus was reached on 54 of 57 statements. The consensus statements highlighted the importance of starting exercise early following diagnosis, ideally before treatment, but tailoring timing of interventions to individual needs. Embedding discussions about exercise into routine oncology consultations and system-level supports were identified as key to ensuring timely access. Conclusion This study provides expert consensus supporting early, individualised exercise prescription and support following cancer diagnosis. These findings offer a foundational framework to guide the development of timely, person-centred exercise models aimed at optimising health outcomes for people with cancer. Cancer exercise rehabilitation timing Figures Figure 1 Figure 2 Introduction Structured, individualised exercise can support people with cancer to optimise physical and psychosocial function, quality of life, reduce treatment side-effects, and ultimately improve survival [ 1 , 2 ]. Exercise is beneficial across all treatment phases and settings, providing both immediate and long-term gains [ 3 , 4 ]. Prior to treatment such as surgery, exercise prehabilitation programs enhance functional capacity and reduce post-operative complications [ 5 , 6 ]. During active treatment, exercise mitigates fatigue, preserves function, and supports treatment adherence [ 3 , 6 ]. Post-treatment, exercise facilitates longer-term recovery, reduces the risk of cancer recurrence, and supports a safe return to premorbid activity [ 3 , 6 ]. A recent review could not conclude whether initiating exercise at one phase of treatment was more effective than initiating treatment at another phase [ 7 ]. Across these treatment phases, guideline-recommended exercise that works towards achieving 150 minutes of moderate to vigorous physical activity plus twice-weekly resistance training can be achieved through structured, group-based exercise rehabilitation programs, trainer-led community fitness services, or independent exercise [ 8 ]. Despite the strong evidence demonstrating the benefits of exercise across all treatment phases [ 3 , 9 , 10 ], the optimal timing to start exercise for people with cancer remains unclear. Patient-level barriers, including fatigue, psychological distress, and competing life demands, can have a negative impact on engagement with exercise at different times [ 11 ]. For example, during treatment, individuals may feel too unwell to exercise, while after treatment, they may prioritise return to daily activities and work [ 12 ]. System-level factors, such as unclear referral systems, extensive wait-times and rigid service structures may further restrict access, reducing uptake despite patient demand [ 13 ]. While comparable benefits may be achieved regardless of timing of initiation [ 7 ], real-world considerations such as access, uptake, adherence, acceptability, and cost-effectiveness can influence when exercise is started. A modified Delphi technique provides a systematic approach for determining expert consensus on the optimal timing of starting exercise for people with cancer. This iterative process gathers opinions from experts to identify areas of agreement and establish recommendations for practice [ 14 ]. Delphi studies have been used to identify key components of exercise oncology services and research priorities [ 15 , 16 ]. Health professionals, given their clinical experience in service delivery, are well placed to inform guidelines regarding when exercise should start through the cancer care trajectory. However, no previous Delphi study has explored expert consensus on the optimal timing for starting exercise for people with cancer. The aim of this study was therefore to use a modified Delphi approach to establish expert consensus on the optimal timing for starting exercise following a cancer diagnosis. Methods Study Design This modified Delphi study followed Conducting and Reporting Delphi Studies (CREDES) guidelines to establish expert consensus on a series of statements related to timing of starting and delivering exercise in cancer [ 17 ] (Appendix 1). The study comprised two phases: (i) an initial stakeholder workshop with an expert steering committee and (ii) three rounds of an iterative online Delphi survey (Fig. 1 ). Modified Delphi studies commonly involve three to five rounds [ 14 ]. In this study, three rounds were chosen to allow iterative feedback and achieve a stable consensus, while minimising participant burden. This approach allowed survey of the range of opinions as well as convergence on a consensus opinion among geographically dispersed participants. Setting This study was conducted online in English, using Research Electronic Data Capture (REDCap) hosted at La Trobe University [ 18 , 19 ]. Sample size We aimed for a sample size of 75 participants. Most Delphi studies conducted in health science research use between 20 and 60 participants and a recent study reported that a minimum sample size of 60–80 participants may provide high levels of replicability [ 20 ]. To allow for a 25% attrition rate [ 21 , 22 ], we aimed to recruit 75 participants. Consensus While there is a lack of agreement as to what constitutes consensus for Delphi studies, most Delphi studies define consensus as between 51 and 100% of participants being in agreement [ 14 ]. In this study, consensus was defined as ≥ 80% agreement or ≥ 80% disagreement. Statements meeting this threshold were removed from subsequent rounds. Statements that did not achieve consensus progressed to the following round [ 14 ], alongside a summary of participant responses from the previous round. The process ended with a group of statements that achieved consensus. In line with quality criteria proposed for conducting Delphi studies [ 14 ], Round 3 would not be completed if consensus was fully achieved by Round 2. Development of survey statements An expert steering committee of 12 stakeholders, including an oncologist (n = 1), cancer nurse coordinators (n = 2), physiotherapists (n = 2), exercise physiologist (n = 1), researchers (n = 5) and a person with lived experience (n = 1), participated in an initial 60-minute workshop to develop and refine an initial list of high priority statements for exercise timing. Feedback was provided by the expert steering committee who met on three occasions to refine the final list of survey statements for Survey Round 1. In this modified Delphi approach, the first round used closed rather than open questions; this method was chosen because data on factors related to timing of cancer exercise rehabilitation have been published and statements were generated through the initial workshop. Selection of experts The term ‘expert’ was defined as an individual who has relevant knowledge and experience in a given field [ 23 , 24 ]. The research team first developed a comprehensive list with the names and contact information of experts prior to dissemination of the Delphi survey. Experts were identified through professional health networks and authorship of peer-reviewed publications (inclusion was limited to first author and/or senior authors) related to exercise and cancer. Contact details were sourced from public domains. People with lived experience or consumers may be included as experts in Delphi studies. In this study, a consumer with lived experience of cancer and exercise rehabilitation was included as a member of the expert steering committee and contributed to the design, conduct and interpretation of the study. Consumers were not included in the Delphi survey rounds as the primary aim was to achieve consensus among health professionals. Future work will focus on disseminating the findings of this study to consumers and the wider public and engaging with them to explore the implications for person-centred exercise care in cancer. Invitation to participate Potential participants received email invitations with study information and a link to the survey. Informed consent was provided within the survey prior to participation. Consistent with snowball sampling, experts were asked to disseminate the request to be involved in the study to relevant contacts who were also provided a link to the survey. Participants Eligibility criteria Experts were eligible to participate in the study if they were health professionals working in any setting with a minimum of five years of clinical or research experience in cancer-related exercise prescription and delivery, referral or program development. Data collection Survey Round 1 comprised of two sections: 1) five demographic and screening questions related to their country, sector of work, primary role, years of experience in cancer or exercise and proficiency in English (Appendix 2) to confirm they met eligibility criteria followed by 2) statements for rating across four domains: i) disease factors (cancer type, stage, time from diagnosis) (n = 12), ii) treatment factors (n = 20), iii) person-related factors (n = 15) and iv) health service-related factors (n = 10). Participants were asked to rate their extent of agreement with each statement on a 9-point Likert scale (1 = Strongly disagree to 9 = Strongly agree). An example of a statement was ‘ Exercise rehabilitation should be initiated as soon as patients are medically stable after diagnosis’ . Participants could provide open-ended feedback to elaborate the reasoning behind their statement ranking or suggest a better description for each individual statement if they thought one was more appropriate. Survey rounds were conducted approximately 4 weeks apart and required 20–30 minutes to complete, with 2-week response windows and reminders (Fig. 1 ). In Round 1, participants were presented with 57 statements (Appendix 3). For Rounds 2 and 3, participants were shown a summary of the quantitative results from the previous round, a synthesis of anonymised feedback and any statement revisions. This allowed participants to consider the group’s responses before re-rating the remaining statements on the 9-point Likert scale. Participants could again provide open-ended feedback, which informed any further refinement in the subsequent round. Data Analysis After each round, responses were analysed using both quantitative and qualitative methods. Quantitatively, median ratings, interquartile ranges, and the proportion of ratings meeting the consensus threshold were described. Statements that met the a priori consensus threshold were removed from subsequent rounds, while those that did not were retained. Open-ended comments were reviewed by two reviewers using a content analysis approach to identify points of clarification, disagreement, or suggested revisions. Based on this feedback, statements could be reworded for clarity, combined with overlapping items, or separated into more specific statements. All changes were reviewed by research team before subsequent rounds. Results Overall, 150 potential experts were identified and contacted for participation in the study. Of these, a total of 80 (53%) responded to the invitation. Of the 80 experts who responded, 78 (98%) completed the screening questions and participated in the first round, 68 (85%) participated in the second round and 67 (83%) participated in the third round (Fig. 2 ). Participants from five continents participated in the study and most (n = 66%) had more than ten years of experience in cancer care (Table 1 ). Most participants (n = 74%) were physiotherapists and exercise physiologists. a 2 statements from Round 1 combined to form 1 statement for Round 2 , b 1 statement from Round 1 was refined into 2 separate statements , c 2 statements from Round 2 combined to form 1 statement for Round 3 Table 1 Participant characteristics. Characteristics No. of participants, n (%) Total participants, n 78 Region of residence Asia 4 (5) Australia/Oceania 53 (68) Europe 8 (10) North America South America 12 (15) 1 (1) Professional background Dietitian 1 (1) Exercise physiologist 11(14) Occupation therapist 2 (3) Physiotherapist 46 (60) Psychologist 1 (1) Oncologist 6 (7) Surgeon 1 (1) Nursing 8 (10) Other 2 (3) Current sector of work Acaedmia/Research 19 (24) Clinical practice: Current clinician 35 (45) Clincal practice: Manager 2 (3) Research/Clinician 9 (12) Clinician/Manager 2 (3) Research/Manager 3 (4) Research/Other 1 (1) Clinician/Education 4 (5) Other 3 (4) Years of experience working in oncology 5 to 10 years 26 (33) More than 10 years 52 (67) First Survey Round At the end of Round 1, 33 of 57 statements achieved consensus (Fig. 2 ). An example of a statement that achieved the highest level of consensus (97%) was ‘ Discussions about exercise should be routinely included by the person’s treating team at key follow-up time-points (e.g. at their 3-monthly, 6-monthly review etc.) ’. A total of 910 comments were collected, analysed and used to update items for Round 2, including merging two statements from Round 1 to form one statement ‘Structured exercise rehabilitation is not usually appropriate for people receiving end-of-life care, unless it is carefully adapted and desired by the person’ (Table 3 ). Twenty-four remaining statements were carried forward to Round 2 (Fig. 2 , Tables 2 – 5 ). Comments are summarised in Appendix 4. Second Survey Round Of 24 statements distributed in Round 2, 14 achieved consensus (Fig. 2 ). In this round, the statement ‘ A person with a culturally and linguistically diverse (CALD) or indigenous background should be provided tailored support by health professionals to engage with exercise rehabilitation early ’ achieved the highest level of consensus (96%). A total of 295 comments were collected (Appendix 4), analysed and used to update items for Round 3, including merging two statements from the second round to form one statement ‘ An appointment to exercise rehabilitation should not be offered until a person feels physically and psychologically ready to participate ’ (Table 4 ). Experts were presented with nine remaining statements for Round 3. Third Survey Round Of nine statements distributed in Round 3, seven achieved consensus (Fig. 2 ). In this round, the statement ‘ Exercise rehabilitation tailored to individual needs and goals is appropriate for people receiving end-of-life care ’ achieved the highest level of consensus (98%). Ninety-three comments were collected and analysed (Appendix 4). Overall, 54 of 57 statements achieved consensus at the end of three survey rounds and completion of the modified Delphi process (Fig. 2 ). Two statements did not reach consensus: (i) that exercise rehabilitation should only be offered once a person feels physically and psychologically ready , and (ii) that exercise should only be initiated when a person has identified goals (Table 3 ). Statements that achieved consensus are presented in their domains in Tables 2 to 5 . Table 2 Delphi survey results: factors related to cancer type, stage and time of diagnosis. Round 1 Round 2 Round 3 Statements that underwent rating, n 12 6 2 Level of Agreement Level of Agreement (%) Median Score (IQR) Level of Agreement (%) Median Score (IQR) Level of Agreement (%) Median Score (IQR) Exercise rehabilitation should be initiated as soon as patients are medically stable after diagnosis 89.8 9 (1) Referral to exercise rehabilitation should be initiated by health professionals within 4 weeks following a cancer diagnosis 86.4 8 (2) Follow-up contact from an exercise professional should ideally be within 2 weeks from receiving a referral 92.6 8.5 (1) Exercise rehabilitation should ideally begin within 3 months following a cancer diagnosis 85.1 8 (1) Discussions about exercise should be routinely included by the person's treating team at key follow-up time-points (e.g. at their 3-monthly, 6-monthly review etc.) 97 9 (1) Referral to exercise rehabilitation should only be initiated when a person reports a decline in physical function 95.6 disagree 1 (1) Exercise rehabilitation can be safely initiated at any time regardless of cancer type, stage and treatment Round 2: Exercise rehabilitation can be safely initiated at any time regardless of cancer type, stage and treatment, provided individualised patient screening has been conducted by a trained exercise professional 76.4 8 (2) 94.1 8 (1) Information about exercise rehabilitation should be provided in the first consultation when a person receives their diagnosis of cancer Round 2: Information about exercise rehabilitation should be introduced at the first consultation (at the time of, or immediately following, diagnosis), provided that it can be done sensitively and with due consideration to the capacity of the patient to receive information 56.4 7 (3) 82.4 8 (1.5) Information about exercise rehabilitation should be initiated in the same consultation when a person receives information about their medical treatment Round 2: Information about exercise rehabilitation should be integrated into any medical consultation in which a person receives information about their medical treatment 70.6 8 (3) 88.3 8 (2) Information and referral to exercise rehabilitation may need to be delayed for a person with advanced cancer receiving complex medical or palliative treatment Round 2: Information and/or referral to exercise rehabilitation should be initiated as early as possible for a person with advanced cancer receiving complex medical or palliative treatment, as long as advice is tailored to individual patient needs 37.3 5.5 (4) 86.3 8 (1.5) Referral to exercise rehabilitation should be initiated in the first consultation when a person receives their diagnosis of cancer Round 2: Everyone should be referred to exercise rehabilitation during the first medical consultation when a person receives their diagnosis of cancer Round 3: It is appropriate to refer a person to exercise rehabilitation during the first medical consultation (at the time of, or immediately following, diagnosis) 47 6 (4) 49.1 6 (2) 85 8 (1) Referral to exercise rehabilitation should be initiated in the same consultation when a person receives information about their medical treatment Round 2: Everyone should be referred to exercise rehabilitation during medical consultations when a person receives information about medical treatment Round 3: Everyone should be offered a referral to exercise rehabilitation during medical consultations when a person receives information about medical treatment 63.7 8 (4) 77.8 8 (2) 90.2 8 (1) Level of Agreement (%): No. of participants who rated moderately agree to strongly agree (%), Red – Did not achieve ≥ 80% consensus, statement was retained to be ranked again in next survey round, green – Achieved ≥ 80% consensus, statement was removed from subsequent survey rounds. Table 3 Delphi survey results: factors related to cancer treatment. Round 1 Round 2 Round 3 Statements that underwent rating, n 20 8 3 Level of Agreement (%) Median Score (IQR) Level of Agreement (%) Median Score (IQR) Level of Agreement (%) Median Score (IQR) Exercise rehabilitation can be safely initiated at any time, regardless of cancer treatment, as long as the person is medically stable 81.8 8 (1) Exercise rehabilitation should only be initiated after a person has completed their cancer treatment 95.5 disagree 1 (1) For people undergoing major cancer surgery (e.g. abdominal resection, open lung surgery, mastectomy, radical prostatectomy), exercise rehabilitation should always be offered prior to surgery as long as a person is medically stable 88 8 (1) Exercise rehabilitation should only be initiated after a person has completed cancer surgery 90.8 disagree 1 (1) Exercise rehabilitation should only be provided from midway through active cancer treatment (e.g. after a few cycles of chemotherapy, radiotherapy, immunotherapy) 87.8 disagree 2 (1) Exercise rehabilitation should only be provided after a person has completed active treatment (e.g. chemotherapy, radiotherapy, immunotherapy) 98.4 disagree 1 (1) Exercise rehabilitation should only be provided to people with cancer after they have commenced maintenance therapy (e.g. hormone replacement or endocrine therapy for breast cancer) 97 disagree 1 (1) Exercise rehabilitation should be initiated for people only if they have a low level of symptom burden (fatigue, pain, nausea) 83.3 disagree 2 (3) Exercise rehabilitation should be initiated only when people have low levels of fatigue 92.5 disagree 2 (1) People who are receiving palliative care should not initiate exercise rehabilitation 95.4 disagree 1 (1) When a person is receiving palliative care, exercise rehabilitation should be initiated as early as possible within the context of their needs and fluctuations in health status 83.2 8 (1) Exercise rehabilitation should be initiated prior to commencement of any cancer treatment Round 2: Health professionals should encourage people to initiate exercise rehabilitation prior to commencement of any cancer treatment, provided there is sufficient time leading up to treatment 60 7 (4) 90.1 8 (1.5) For patients receiving non-surgical interventions, exercise rehabilitation should be initiated shortly after a person starts their cancer treatment (e.g. after 1st cycle of chemotherapy, radiotherapy, immunotherapy) Round 2: For patients receiving non-surgical interventions, exercise rehabilitation should be initiated before rather than after a person starts their cancer treatment (e.g. before 1st cycle of chemotherapy, radiotherapy, immunotherapy) 46.9 6 (5) 84.3 8 (2) Exercise rehabilitation should be initiated as soon as a person has reported any side effects (fatigue, neuropathy, cardiac dysfunction) Round 2: Exercise rehabilitation should only be initiated if a person reports any side effects (fatigue, neuropathy, cardiac dysfunction) from cancer treatment 48.5 6 (6) 86.3 disagree 1 (1) Exercise rehabilitation should be initiated only after serious medical complications (febrile neutropaenia, severe fatigue) have resolved Round 2: Exercise rehabilitation may need to be delayed if a patient has serious medical complications (febrile neutropaenia, deep vein thrombosis) 33.3 4 (7) 88.2 8 (1.5) Exercise rehabilitation should be delayed for people who have high levels of symptom burden (fatigue, pain, nausea) Round 2: Exercise rehabilitation should be initiated and modified accordingly for people who have high levels of symptom burden (fatigue, pain, nausea) 62.1 2 (2) 82.4 8 (1) Exercise rehabilitation should only be initiated prior to cancer surgery if a person has an expected window of ≥ 4–6 weeks from diagnosis to surgery Round 2: Exercise rehabilitation should only be initiated prior to cancer surgery if a person is expected to have at least 2–3 weeks to participate prior to surgery Round 3: Exercise rehabilitation should be initiated prior to cancer surgery, regardless of the time a patient has from diagnosis to surgery 69.6 disagree 2 (3) 51 7 (6) 88.6 8 (1) For people with haematological cancer, exercise rehabilitation should only be provided after a person has received their stem cell transplant and has been discharged from hospital Round 2: For people with haematological cancer, exercise rehabilitation should be initiated before rather than after a person has received their stem cell transplant Round 3: For people with haematological cancer, exercise rehabilitation should be initiated prior to their stem cell transplant, regardless of the time to transplant 77.3 disagree 2 (2) 72.5 8 (3) 88.5 8 (2) People receiving end-of-life care should not initiate exercise rehabilitation a Round 2: Structured exercise rehabilitation is not usually appropriate for people receiving end-of-life care, unless it is carefully adapted and desired by the person Round 3: Exercise rehabilitation tailored to individual needs and goals is appropriate for people receiving end-of-life care c 57.5 disagree 3 (3) 66.6 8 (2.5) 98.4 8 (1) Exercise rehabilitation should only be initiated if it is a priority for a person receiving end-of-life care b 56 7 (3) Following Round 1, two statements a,b were combined to form one statement c . Level of Agreement (%): No. of participants who rated moderately agree to strongly agree (%), Red – Did not achieve ≥ 80% consensus, statement was retained to be ranked again in next survey round, green – Achieved ≥ 80% consensus, statement was removed from subsequent survey rounds. Table 4 Delphi survey results: person-related factors. Round 1 Round 2 Round 3 Statements that underwent rating, n 15 6 4 Level of Agreement Level of Agreement (%) Median Score (IQR) Level of Agreement (%) Median Score (IQR) Level of Agreement (%) Median Score (IQR) It is important to assess a person's physical and psychological readiness to determine whether they should start exercise rehabilitation earlier rather than later 84.8 8 (2) Exercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) only if a person is confident to exercise 86.4 2 (1) Exercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) only if a person is less confident to exercise 80.4 2 (2) A flexible approach to the timing of exercise rehabilitation is required to support people who have competing priorities (medical appointments, work, family) 95.5 9 (1) Exercise rehabilitation should be initiated earlier rather than later for a person with co-morbidities or complex health issues (cardiovascular disease, diabetes, osteoporosis etc.) 86.3 8 (1) People with decreased psychosocial support should be provided extra support by health professionals to start exercise rehabilitation earlier rather than later 86.4 8 (2) Exercise rehabilitation should be initiated only when a person has minimal or no competing priorities (e.g. medical appointments, work, family) 91 disagree 2 (1) Exercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) only if a person has exercise experience 90.9 disagree 1 (1) Exercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) only if a person who has little or no experience with exercise 83.2 disagree 2 (1) A person with a culturally and linguistically diverse (CALD) or indigenous background should be provided extra support by health professionals to start exercise rehabilitation earlier rather than later Round 2: A person with a culturally and linguistically diverse (CALD) or indigenous background should be provided tailored support by health professionals to engage in exercise rehabilitation early 77.2 8 (2) 96.1 8 (1) A person with co-morbidities or complex health issues (cardiovascular disease, diabetes, osteoporosis etc) may need to delay their initiation of exercise rehabilitation Round 2: A person with co-morbidities or complex health issues (cardiovascular disease, diabetes, osteoporosis etc) may need to delay their initiation of exercise rehabilitation if they are not medically stable 48.5 disagree 4 (4) 78.4 8 (1) 86.3 8 (1) Exercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) only if a person is motivated to exercise Round 2: Exercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) regardless of the motivation of the person to exercise 40.9 disagree 4 (4) 78.4 7 (2.5) 93.3 8 (1) Exercise rehabilitation should be initiated as soon as a person feels physically ready to participate a Round 3. An appointment to exercise rehabilitation should not be offered until a person feels physically and psychologically ready to participate c 56 7 (3) 39.2 5 (4) 41.7 4 (5) Exercise rehabilitation should be initiated as soon as a person feels psychologically ready to participate b 60.5 7 (2) 52.9 6 (4) Following Round 2, two statements a,b were combined to form one statement c . A person's personal goals for recovery impact whether they start exercise rehabilitation earlier or later Round 2: Starting exercise rehabilitation early depends on a person's personal goals for recovery Round 3. An appointment to exercise rehabilitation should be offered only when a person has identified goals 60.6 7 (3) 49 6 (3) 71.1 disagree 2 (2) Level of Agreement (%): No. of participants who rated moderately agree to strongly agree (%), Red – Did not achieve ≥ 80% consensus, statement was retained to be ranked again in next survey round, green – Achieved ≥ 80% consensus, statement was removed from subsequent survey rounds. Table 5 Delphi survey results: health service-related factors. Round 1 Round 2 Round 3 Statements that underwent rating, n 10 4 0 Level of Agreement Level of Agreement (%) Median Score (IQR) Level of Agreement (%) Median Score (IQR) Level of Agreement (%) Median Score (IQR) Exercise rehabilitation programs that are free, low-cost or offer financial hardship options support a person to initiate exercise rehabilitation earlier rather than later 95.5 9 (1) Health services that are easily accessible (ample parking, convenient location, affordable or free parking) support people to initiate exercise rehabilitation earlier rather than later 95.5 9 (1) Access to qualified exercise professionals co-located within a cancer treatment centre supports a person to initiate exercise rehabilitation earlier rather than later 92.4 9 (1) Exercise rehabilitation offered via telehealth support people to initiate exercise rehabilitation earlier rather than later 87.9 8 (2) Long service waitlists delay the initiation of exercise rehabilitation 84.9 8 (1) Complex referral pathways delay the initiation of exercise rehabilitation 84.8 8 (2) Education and information on exercise rehabilitation provided by consumer advocacy groups is useful in promoting early referral to exercise rehabilitation services 80.3 8 (2) Having too many other medical appointments or medical appointments that clash with exercise rehabilitation session times prohibits people to start exercise rehabilitation Round 2: Having too many other medical appointments or medical appointments that clash with exercise rehabilitation session times prohibits people to start exercise rehabilitation early 78.2 8 (1) 90 8 (1) Online resources such as exercise videos and apps support people to initiate exercise rehabilitation earlier rather than later Round 2: Where patients have no access to exercise professionals, online resources such as evidence-based exercise videos or apps prepared by cancer exercise professionals can be used to support people to initiate exercise rehabilitation earlier rather than later 78.8 8 (2) 92.2 8 (1) Having to travel to a different hospital or community gym outside of their main cancer treatment centre may delay a person's initiation of exercise rehabilitation Round 2 (Refined into two statements a,b ) 72.7 8 (2) Following Round 1, statement was refined into two separate statements a,b a Having exercise rehabilitation co-located with medical cancer treatment centres supports a person to initiate exercise rehabilitation earlier rather than later 88.2 8 (1) b Community-based exercise rehabilitation may support a person to initiate exercise rehabilitation earlier rather than later 84.2 8 (0.5) Level of Agreement (%): No. of participants who rated moderately agree to strongly agree (%), Red – Did not achieve ≥ 80% consensus, statement was retained to be ranked again in next survey round, green – Achieved ≥ 80% consensus, statement was removed from subsequent survey rounds. Discussion This modified Delphi study achieved international, multidisciplinary consensus on 54 statements to optimise the timing of exercise support in people with cancer. Engagement remained high across all rounds, with 83% of participants from Round 1 completing the final survey. Consensus highlighted four key findings: (i) exercise should be advised and offered as early as medically appropriate after a cancer diagnosis; (ii) a flexible, individualised approach is essential when starting exercise; (iii) discussion about exercise and referral to support services should be embedded within routine medical consultations; and (iv) system-level infrastructure is needed to facilitate timely access to exercise. The consensus achieved in this study reinforces current position statements recommending the integration of exercise as part of standard cancer care [ 25 – 27 ] and further strengthens the evidence by explicitly stating that exercise should be implemented as an early, proactive component of care rather than as a reactive intervention. Clinical Implications Starting exercise following a cancer diagnosis should be proactive rather than reactive. This aligns with the principles of prehabilitation, where exercise is prescribed prior to medical treatment such as surgery and chemotherapy with the aim of optimising health outcomes, post-treatment recovery and mitigating functional decline [ 9 , 28 , 29 ]. Emerging evidence demonstrates that even brief pre-operative exercise interventions, two to three weeks in duration, can improve functional capacity, postoperative recovery [ 30 ] and contribute to a significant reduction in hospital length of stay [ 28 , 31 ] while demonstrating cost effectiveness [ 32 ]. This approach has continued to gain traction with peak professional health bodies recommending exercise as part of standard care in clinical practice guidelines [ 33 ]. However, early exercise commencement in real-world settings must account for each patient’s circumstances such as readiness, symptom burden, psychosocial context, and competing demands, reflecting the heterogeneity of disease and treatment trajectories especially in the context of comorbidity and people from diverse backgrounds. All treating clinicians should reinforce and offer regular exercise advice and facilitate referral within routine clinical consultations and at key milestones. Patients may often be unsure and feel unprepared to start exercise but rather than waiting for patients to be ready [ 34 ], clinicians may find value in using an exercise consultation as an opportunity to improve a patient’s self-efficacy and facilitate behaviour change. Previous research has shown that when exercise is endorsed by oncologists and integrated into treatment discussions, referral rates and program adherence improve [ 35 , 36 ]. Yet these expectations contrast with current practice, where time pressures, competing clinical priorities, workplace culture, variable clinician confidence, and limited access to cancer exercise programs often result in ad-hoc or delayed referrals [ 37 ]. Without system-level structures to standardise follow-up and review, exercise pathways remain dependent on individual clinicians, producing inconsistent and inequitable implementation. Having the right systems, services, and support structures in place is crucial to help cancer patients start exercising early as part of their care. The expert statements in this study reflect challenges in implementation across both the inner and outer settings of the Consolidated Framework for Implementation Research (CFIR) framework [ 38 ]. Experts identified inner-setting barriers such as complex referral pathways, long waitlists, and insufficient access to qualified exercise professionals, all of which contribute to fragmented implementation and delayed engagement. Barriers across the outer setting including workforce shortages, funding constraints and lack of programs further increase inequities in access. Enablers included accessible and affordable programs and health professionals with expertise in exercise, co-located exercise services within cancer treatment centres [ 39 ] and community-based or telehealth models [ 40 , 41 ], reflecting previous findings that addressing logistical and financial barriers improves engagement [ 37 ]. In settings where cancer exercise services are unavailable, online resources and consumer advocacy groups were viewed as valuable outer-setting supports that can promote early engagement. These findings provide expert direction for health professionals on implementing exercise guidelines in cancer care and support clinicians in delivering timely, consistent, and person-centred exercise interventions. By addressing when and how exercise should be offered, alongside the infrastructure, resources, and system-level supports required for implementation, the findings align with the AGREE II applicability domain, which emphasises the practical translation of recommendations into clinical practice [ 42 ]. Strengths and Limitations We included a large, multidisciplinary, international expert panel of health professionals with clinical, research and health administrative experience in exercise for people with cancer. Statements were created in an iterative, collaborative process between clinicians, researchers and consumers. High retention rates across three rounds (83%) and strong engagement with open-ended feedback further strengthens confidence in the reliability of the consensus. Despite multidisciplinary participation, representation from medical specialists such as oncologists and surgeons was limited. This is important as medical specialists can influence patient behaviour and have early conversations with patients where exercise can be discussed and recommended. This was balanced by strong representation from professionals who are viewed by the cancer care team as experts in exercise. While consumers were included in the initial stakeholder workshop and development of survey statements, the exclusion of consumers from the Delphi rounds may have limited insight into the perspectives and lived experiences of people with cancer. Future research should explore the perspectives of patients on the factors influencing the optimal timing of starting exercise following cancer. The number and range of open-ended feedback provided across all survey rounds reflects strong professional engagement and recognition of the importance of exercise timing. While detailed feedback was incorporated into subsequent survey statements using standardised methods, some specificity may have been lost. The online survey platform ensured participant anonymity and convenience but limited the opportunities for collaborative discussion with participants. While grounded in expert consensus, the impact of strategies identified in this study on improving outcomes for people with cancer remains unknown. A key next step will be to evaluate these consensus-informed strategies in clinical trials to determine whether their implementation improves access and translates into better outcomes for people with cancer. Conclusion This study provides expert consensus that exercise should be started as early as medically appropriate after cancer diagnosis, with exercise discussion and referral embedded into routine oncology consultations, and tailored to each patient’s health status, needs and readiness. These findings provide a practical framework to guide the development of timely, person-centred exercise pathways and offer guidance on implementing broad position statement recommendations into clinical practice [ 43 ]. Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Germaine A Tan is supported by the La Trobe University and NHMRC Graduate Researcher Scholarship (Grant #2031419). Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Germaine A Tan, Casey L Peiris, Nicholas F Taylor, Katherine E Harding and Amy M Dennett. The first draft of the manuscript was written by Germaine A Tan and all authors reviewed and drafted previous versions of the manuscript. All authors read and approved the final manuscript. Ethics Approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the La Trobe University Human Research Ethics Committee (Approval Ref No. HEC25054). Consent to participate Informed consent was obtained from all individual participants included in the study. Consent to publish Informed consent was obtained from all individual participants included in the study. Data Availability Data from this study are available from the corresponding author on reasonable request and following appropriate ethical approval. Acknowledgements The authors would like to thank all participants for their valuable comments and their contribution to this study. The authors also thank our Steering Committee for participating in our initial stakeholder workshop and pilot testing of surveys. References Courneya KS, Vardy JL, O'Callaghan CJ, et al. 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Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401–9. doi: 10.1016/j.jclinepi.2013.12.002 Kennedy MA, Wood KC, Campbell A, et al. Identification of core competencies for exercise oncology professionals: A Delphi study of United States and Australian participants. Cancer Med. 2024;13(14):e70004. doi: 10.1002/cam4.70004 Edbrooke L, Davies TW, Granger CL, et al. Development of a clinical core outcome set to evaluate lung cancer rehabilitation. ERJ Open Res. 2025;11(5). doi: 10.1183/23120541.00058-2025 Jünger S, Payne SA, Brine J, et al. Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review. Palliat Med. 2017;31(8):684–706. doi: 10.1177/0269216317690685 Harris PA, Taylor R, Thielke R, et al. 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A Delphi study to build consensus on the definition and use of big data in obesity research. International Journal of Obesity. 2019;43(12):2573–86. doi: 10.1038/s41366-018-0313-9 Hohmann E, Brand JC, Rossi MJ, et al. Expert Opinion Is Necessary: Delphi Panel Methodology Facilitates a Scientific Approach to Consensus. Arthroscopy. 2018;34(2):349–51. doi: 10.1016/j.arthro.2017.11.022 Chia-Chien H, Brian AS. The Delphi Technique: Making Sense of Consensus. Practical Assessment, Research, and Evaluation. 2007;12(1). doi: 10.7275/pdz9-th90 Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019;51(11):2375–90. Cormie P, Trevaskis M, Thornton-Benko E, Zopf E. Exercise medicine in cancer care. Australian Journal of General Practice. 2020;49:169–74. Hart NH, Nekhlyudov L, Smith TJ, Yee J, Fitch MI, Crawford GB, et al. Survivorship care for people affected by advanced or metastatic cancer: MASCC-ASCO standards and practice recommendations. Support Care Cancer. 2024;32(5):313. Waterland JL, McCourt O, Edbrooke L, et al. Efficacy of Prehabilitation Including Exercise on Postoperative Outcomes Following Abdominal Cancer Surgery: A Systematic Review and Meta-Analysis. Front Surg. 2021;8:628848. doi: 10.3389/fsurg.2021.628848 Denehy L, Edbrooke L. The Role of Exercise Before Cancer Treatment. Seminars in Oncology Nursing. 2022;38(5):151330. doi: 10.1016/j.soncn.2022.151330 Granger C, Cavalheri V. Preoperative exercise training for people wit h non-small cell lung cancer. Cochrane Database of Systematic Reviews. 2022(9). doi: 10.1002/14651858.CD012020.pub3 Meneses-Echavez JF, Loaiza-Betancur AF, Díaz-López V, et al. Prehabilitation programs for individuals with cancer: a systematic review of randomized-controlled trials. Systematic Reviews. 2023;12(1):219. doi: 10.1186/s13643-023-02373-4 Sabajo CR, ten Cate DWG, Heijmans MHM, et al. Prehabilitation in colorectal cancer surgery improves outcome and reduces hospital costs. European Journal of Surgical Oncology. 2024;50(1). doi: 10.1016/j.ejso.2023.107302 Macmillan Cancer Support (2025) Prehabilitation for people with cancer: clinical and implementation guidelines. Prehabilitation resources for healthcare professionals | Macmillan Cancer Support. Dennett AM, Shields N, Barton C, et al. 'Making a connection': a qualitative study of experiences from a cancer telerehabilitation program. Support Care Cancer. 2024;32(10):636. doi: 10.1007/s00520-024-08803-w Kirkham AA, Van Patten CL, Gelmon KA, et al. Effectiveness of Oncologist-Referred Exercise and Healthy Eating Programming as a Part of Supportive Adjuvant Care for Early Breast Cancer. Oncologist. 2018;23(1):105–15. doi: 10.1634/theoncologist.2017-0141 Jones LW, Courneya KS, Fairey AS, et al. Effects of an oncologist's recommendation to exercise on self-reported exercise behavior in newly diagnosed breast cancer survivors: a single-blind, randomized controlled trial. Ann Behav Med. 2004;28(2):105–13. doi: 10.1207/s15324796abm2802_5 Schmitz KH, Campbell AM, Stuiver MM, et al. Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA: A Cancer Journal for Clinicians. 2019;69(6):468–84. doi: 10.3322/caac.21579 Damschroder LJ, Reardon CM, Widerquist MAO, et al. The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Science. 2022;17(1):75. doi: 10.1186/s13012-022-01245-0 Dennett AM, Zappa B, Wong R, et al. Bridging the gap: a pre-post feasibility study of embedding exercise therapy into a co-located cancer unit. Supportive Care in Cancer. 2021;29(11):6701–11. doi: 10.1007/s00520-021-06261-2 Tan GA, Dennett AM, Nagarajan D et al. Program for Oncology Wellness and Exercise Rehabilitation (POWER): A Feasibility Study of Oncology Rehabilitation in the Community. Journal of Cancer Rehabilitation. 2020;3:30–9. doi: 10.48252/JCR1 Dennett A, Harding KE, Reimert J, et al. Telerehabilitation's Safety, Feasibility, and Exercise Uptake in Cancer Survivors: Process Evaluation. JMIR Cancer. 2021;7(4):e33130. doi: 10.2196/33130 Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. Cmaj. 2010;182(18):E839-42. doi: 10.1503/cmaj.090449 Dijkers MP, Ward I, Annaswamy T, et al. Quality of Rehabilitation Clinical Practice Guidelines: An Overview Study of AGREE II Appraisals. Archives of Physical Medicine and Rehabilitation. 2020;101(9):1643–55. doi: 10.1016/j.apmr.2020.03.022 Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 04 May, 2026 Reviewers agreed at journal 15 Mar, 2026 Reviewers invited by journal 15 Mar, 2026 Editor assigned by journal 15 Mar, 2026 Submission checks completed at journal 12 Feb, 2026 First submitted to journal 10 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8846045","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":606581673,"identity":"243cde32-d919-40c6-9d58-220a9dab78c1","order_by":0,"name":"Germaine A Tan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYNCCCgsQyQYiGBsIK2cG4jMSDDykaWFsI0WLvAP/wc+F8yTk7aUPH3vwgcFGdsMB5mcS+LQYHmBmlp65TcKwhy8t3XAGQ5rxhgNsZvi1NDAzSPNuk2Ds4eExk+ZhOJy44QADQS3Mv3nnSNiDtfxh+A/Uwv4NrxZ5BmY2ad4GiUSwFgaGA0AtPPhtMWBmNrPmOSaR3HOGLd2wxyDZeOZhnmILvLa0Nz6+zVNjY9vew3zswY8KO9m+4+0bb+C15TAqlwESt3htaSCgYBSMglEwCkYBAwDCUD0oXY5lGQAAAABJRU5ErkJggg==","orcid":"","institution":"La Trobe University","correspondingAuthor":true,"prefix":"","firstName":"Germaine","middleName":"A","lastName":"Tan","suffix":""},{"id":606581674,"identity":"b2c44b82-34c0-4154-b8d8-eca5c076d5fb","order_by":1,"name":"Casey L Peiris","email":"","orcid":"","institution":"La Trobe University","correspondingAuthor":false,"prefix":"","firstName":"Casey","middleName":"L","lastName":"Peiris","suffix":""},{"id":606581675,"identity":"2b59a90f-1e78-4e00-9ef2-5fd7504b1206","order_by":2,"name":"Nicholas F 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01:38:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8846045/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8846045/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104814583,"identity":"42b634cf-9f71-4f77-9862-cd3b7068fd43","added_by":"auto","created_at":"2026-03-17 13:13:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":170403,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDelphi Study timeline.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8846045/v1/2b0fcb1f208f12157f2c7577.png"},{"id":104814551,"identity":"2354979a-ab0a-4110-b4d9-3d9762e5b267","added_by":"auto","created_at":"2026-03-17 13:12:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":180281,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipant flow and outcomes through study.\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\n\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e2 statements from Round 1 combined to form 1 statement for Round 2,\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u0026nbsp;b\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e1 statement from Round 1 was refined into 2 separate statements,\u0026nbsp;\u003c/em\u003e\u003csup\u003e\u003cem\u003ec\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e2 statements from Round 2 combined to form 1 statement for Round 3\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8846045/v1/a00ee137774172d60b2e680b.png"},{"id":104835347,"identity":"557c13a8-f567-4d66-ac82-07c5762431b6","added_by":"auto","created_at":"2026-03-17 17:44:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5377935,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8846045/v1/175efec0-c399-4db0-94e0-a9089cb74582.pdf"},{"id":104814584,"identity":"00c0822f-ce5b-4d1f-a129-a4ef84db2f50","added_by":"auto","created_at":"2026-03-17 13:13:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":4885642,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8846045/v1/85d41f6e38ce95455db1a439.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"When is the best time to start exercise after a cancer diagnosis? A modified Delphi consensus study of expert health professionals","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStructured, individualised exercise can support people with cancer to optimise physical and psychosocial function, quality of life, reduce treatment side-effects, and ultimately improve survival [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Exercise is beneficial across all treatment phases and settings, providing both immediate and long-term gains [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Prior to treatment such as surgery, exercise prehabilitation programs enhance functional capacity and reduce post-operative complications [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. During active treatment, exercise mitigates fatigue, preserves function, and supports treatment adherence [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Post-treatment, exercise facilitates longer-term recovery, reduces the risk of cancer recurrence, and supports a safe return to premorbid activity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A recent review could not conclude whether initiating exercise at one phase of treatment was more effective than initiating treatment at another phase [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Across these treatment phases, guideline-recommended exercise that works towards achieving 150 minutes of moderate to vigorous physical activity plus twice-weekly resistance training can be achieved through structured, group-based exercise rehabilitation programs, trainer-led community fitness services, or independent exercise [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the strong evidence demonstrating the benefits of exercise across all treatment phases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], the optimal timing to start exercise for people with cancer remains unclear. Patient-level barriers, including fatigue, psychological distress, and competing life demands, can have a negative impact on engagement with exercise at different times [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. For example, during treatment, individuals may feel too unwell to exercise, while after treatment, they may prioritise return to daily activities and work [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. System-level factors, such as unclear referral systems, extensive wait-times and rigid service structures may further restrict access, reducing uptake despite patient demand [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. While comparable benefits may be achieved regardless of timing of initiation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], real-world considerations such as access, uptake, adherence, acceptability, and cost-effectiveness can influence when exercise is started.\u003c/p\u003e \u003cp\u003eA modified Delphi technique provides a systematic approach for determining expert consensus on the optimal timing of starting exercise for people with cancer. This iterative process gathers opinions from experts to identify areas of agreement and establish recommendations for practice [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Delphi studies have been used to identify key components of exercise oncology services and research priorities [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Health professionals, given their clinical experience in service delivery, are well placed to inform guidelines regarding when exercise should start through the cancer care trajectory. However, no previous Delphi study has explored expert consensus on the optimal timing for starting exercise for people with cancer.\u003c/p\u003e \u003cp\u003eThe aim of this study was therefore to use a modified Delphi approach to establish expert consensus on the optimal timing for starting exercise following a cancer diagnosis.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis modified Delphi study followed Conducting and Reporting Delphi Studies (CREDES) guidelines to establish expert consensus on a series of statements related to timing of starting and delivering exercise in cancer [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] (Appendix 1). The study comprised two phases: (i) an initial stakeholder workshop with an expert steering committee and (ii) three rounds of an iterative online Delphi survey (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Modified Delphi studies commonly involve three to five rounds [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In this study, three rounds were chosen to allow iterative feedback and achieve a stable consensus, while minimising participant burden. This approach allowed survey of the range of opinions as well as convergence on a consensus opinion among geographically dispersed participants.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThis study was conducted online in English, using Research Electronic Data Capture (REDCap) hosted at La Trobe University [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eSample size\u003c/h3\u003e\n\u003cp\u003e We aimed for a sample size of 75 participants. Most Delphi studies conducted in health science research use between 20 and 60 participants and a recent study reported that a minimum sample size of 60\u0026ndash;80 participants may provide high levels of replicability [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. To allow for a 25% attrition rate [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], we aimed to recruit 75 participants.\u003c/p\u003e\n\u003ch3\u003eConsensus\u003c/h3\u003e\n\u003cp\u003eWhile there is a lack of agreement as to what constitutes consensus for Delphi studies, most Delphi studies define consensus as between 51 and 100% of participants being in agreement [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In this study, consensus was defined as \u0026ge;\u0026thinsp;80% agreement or \u0026ge;\u0026thinsp;80% disagreement. Statements meeting this threshold were removed from subsequent rounds. Statements that did not achieve consensus progressed to the following round [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], alongside a summary of participant responses from the previous round. The process ended with a group of statements that achieved consensus. In line with quality criteria proposed for conducting Delphi studies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], Round 3 would not be completed if consensus was fully achieved by Round 2.\u003c/p\u003e\n\u003ch3\u003eDevelopment of survey statements\u003c/h3\u003e\n\u003cp\u003e An expert steering committee of 12 stakeholders, including an oncologist (n\u0026thinsp;=\u0026thinsp;1), cancer nurse coordinators (n\u0026thinsp;=\u0026thinsp;2), physiotherapists (n\u0026thinsp;=\u0026thinsp;2), exercise physiologist (n\u0026thinsp;=\u0026thinsp;1), researchers (n\u0026thinsp;=\u0026thinsp;5) and a person with lived experience (n\u0026thinsp;=\u0026thinsp;1), participated in an initial 60-minute workshop to develop and refine an initial list of high priority statements for exercise timing. Feedback was provided by the expert steering committee who met on three occasions to refine the final list of survey statements for Survey Round 1.\u003c/p\u003e \u003cp\u003eIn this modified Delphi approach, the first round used closed rather than open questions; this method was chosen because data on factors related to timing of cancer exercise rehabilitation have been published and statements were generated through the initial workshop.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSelection of experts\u003c/h2\u003e \u003cp\u003eThe term \u0026lsquo;expert\u0026rsquo; was defined as an individual who has relevant knowledge and experience in a given field [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The research team first developed a comprehensive list with the names and contact information of experts prior to dissemination of the Delphi survey. Experts were identified through professional health networks and authorship of peer-reviewed publications (inclusion was limited to first author and/or senior authors) related to exercise and cancer. Contact details were sourced from public domains.\u003c/p\u003e \u003cp\u003ePeople with lived experience or consumers may be included as experts in Delphi studies. In this study, a consumer with lived experience of cancer and exercise rehabilitation was included as a member of the expert steering committee and contributed to the design, conduct and interpretation of the study. Consumers were not included in the Delphi survey rounds as the primary aim was to achieve consensus among health professionals. Future work will focus on disseminating the findings of this study to consumers and the wider public and engaging with them to explore the implications for person-centred exercise care in cancer.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInvitation to participate\u003c/h3\u003e\n\u003cp\u003ePotential participants received email invitations with study information and a link to the survey. Informed consent was provided within the survey prior to participation. Consistent with snowball sampling, experts were asked to disseminate the request to be involved in the study to relevant contacts who were also provided a link to the survey.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEligibility criteria\u003c/h2\u003e \u003cp\u003eExperts were eligible to participate in the study if they were health professionals working in any setting with a minimum of five years of clinical or research experience in cancer-related exercise prescription and delivery, referral or program development.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eSurvey Round 1 comprised of two sections: 1) five demographic and screening questions related to their country, sector of work, primary role, years of experience in cancer or exercise and proficiency in English (Appendix 2) to confirm they met eligibility criteria followed by 2) statements for rating across four domains: i) disease factors (cancer type, stage, time from diagnosis) (n\u0026thinsp;=\u0026thinsp;12), ii) treatment factors (n\u0026thinsp;=\u0026thinsp;20), iii) person-related factors (n\u0026thinsp;=\u0026thinsp;15) and iv) health service-related factors (n\u0026thinsp;=\u0026thinsp;10). Participants were asked to rate their extent of agreement with each statement on a 9-point Likert scale (1\u0026thinsp;=\u0026thinsp;Strongly disagree to 9\u0026thinsp;=\u0026thinsp;Strongly agree). An example of a statement was \u0026lsquo;\u003cem\u003eExercise rehabilitation should be initiated as soon as patients are medically stable after diagnosis\u0026rsquo;\u003c/em\u003e. Participants could provide open-ended feedback to elaborate the reasoning behind their statement ranking or suggest a better description for each individual statement if they thought one was more appropriate. Survey rounds were conducted approximately 4 weeks apart and required 20\u0026ndash;30 minutes to complete, with 2-week response windows and reminders (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Round 1, participants were presented with 57 statements (Appendix 3).\u003c/p\u003e \u003cp\u003eFor Rounds 2 and 3, participants were shown a summary of the quantitative results from the previous round, a synthesis of anonymised feedback and any statement revisions. This allowed participants to consider the group\u0026rsquo;s responses before re-rating the remaining statements on the 9-point Likert scale. Participants could again provide open-ended feedback, which informed any further refinement in the subsequent round.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eAfter each round, responses were analysed using both quantitative and qualitative methods. Quantitatively, median ratings, interquartile ranges, and the proportion of ratings meeting the consensus threshold were described. Statements that met the a priori consensus threshold were removed from subsequent rounds, while those that did not were retained.\u003c/p\u003e \u003cp\u003eOpen-ended comments were reviewed by two reviewers using a content analysis approach to identify points of clarification, disagreement, or suggested revisions. Based on this feedback, statements could be reworded for clarity, combined with overlapping items, or separated into more specific statements. All changes were reviewed by research team before subsequent rounds.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOverall, 150 potential experts were identified and contacted for participation in the study. Of these, a total of 80 (53%) responded to the invitation. Of the 80 experts who responded, 78 (98%) completed the screening questions and participated in the first round, 68 (85%) participated in the second round and 67 (83%) participated in the third round (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants from five continents participated in the study and most (n\u0026thinsp;=\u0026thinsp;66%) had more than ten years of experience in cancer care (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Most participants (n\u0026thinsp;=\u0026thinsp;74%) were physiotherapists and exercise physiologists.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cem\u003ea\u003c/em\u003e \u003c/sup\u003e \u003cem\u003e2 statements from Round 1 combined to form 1 statement for Round 2\u003c/em\u003e, \u003csup\u003e\u003cem\u003eb\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e1 statement from Round 1 was refined into 2 separate statements\u003c/em\u003e, \u003csup\u003e\u003cem\u003ec\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e2 statements from Round 2 combined to form 1 statement for Round 3\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo. of participants, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal participants, n\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRegion of residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAustralia/Oceania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth America\u003c/p\u003e \u003cp\u003eSouth America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (15)\u003c/p\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessional background\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDietitian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise physiologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation therapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiotherapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOncologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent sector of work\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcaedmia/Research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical practice: Current clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClincal practice: Manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResearch/Clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinician/Manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResearch/Manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResearch/Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinician/Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of experience working in oncology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 to 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFirst Survey Round\u003c/h2\u003e \u003cp\u003eAt the end of Round 1, 33 of 57 statements achieved consensus (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). An example of a statement that achieved the highest level of consensus (97%) was \u0026lsquo;\u003cem\u003eDiscussions about exercise should be routinely included by the person\u0026rsquo;s treating team at key follow-up time-points (e.g. at their 3-monthly, 6-monthly review etc.)\u003c/em\u003e\u0026rsquo;. A total of 910 comments were collected, analysed and used to update items for Round 2, including merging two statements from Round 1 to form one statement \u003cem\u003e\u0026lsquo;Structured exercise rehabilitation is not usually appropriate for people receiving end-of-life care, unless it is carefully adapted and desired by the person\u0026rsquo;\u003c/em\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Twenty-four remaining statements were carried forward to Round 2 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Comments are summarised in Appendix 4.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSecond Survey Round\u003c/h2\u003e \u003cp\u003eOf 24 statements distributed in Round 2, 14 achieved consensus (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In this round, the statement \u0026lsquo;\u003cem\u003eA person with a culturally and linguistically diverse (CALD) or indigenous background should be provided tailored support by health professionals to engage with exercise rehabilitation early\u003c/em\u003e\u0026rsquo; achieved the highest level of consensus (96%). A total of 295 comments were collected (Appendix 4), analysed and used to update items for Round 3, including merging two statements from the second round to form one statement \u0026lsquo;\u003cem\u003eAn appointment to exercise rehabilitation should not be offered until a person feels physically and psychologically ready to participate\u003c/em\u003e\u0026rsquo; (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Experts were presented with nine remaining statements for Round 3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eThird Survey Round\u003c/h2\u003e \u003cp\u003eOf nine statements distributed in Round 3, seven achieved consensus (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In this round, the statement \u0026lsquo;\u003cem\u003eExercise rehabilitation tailored to individual needs and goals is appropriate for people receiving end-of-life care\u003c/em\u003e\u0026rsquo; achieved the highest level of consensus (98%). Ninety-three comments were collected and analysed (Appendix 4).\u003c/p\u003e \u003cp\u003eOverall, 54 of 57 statements achieved consensus at the end of three survey rounds and completion of the modified Delphi process (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Two statements did not reach consensus: (i) \u003cem\u003ethat exercise rehabilitation should only be offered once a person feels physically and psychologically ready\u003c/em\u003e, and (ii) \u003cem\u003ethat exercise should only be initiated when a person has identified goals\u003c/em\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Statements that achieved consensus are presented in their domains in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e to \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDelphi survey results: factors related to cancer type, stage and time of diagnosis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRound 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eRound 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eRound 3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatements that underwent rating, n\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should be initiated as soon as patients are medically stable after diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReferral to exercise rehabilitation should be initiated by health professionals within 4 weeks following a cancer diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFollow-up contact from an exercise professional should ideally be within 2 weeks from receiving a referral\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should ideally begin within 3 months following a cancer diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiscussions about exercise should be routinely included by the person's treating team at key follow-up time-points (e.g. at their 3-monthly, 6-monthly review etc.)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReferral to exercise rehabilitation should only be initiated when a person reports a decline in physical function\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.6\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise rehabilitation can be safely initiated at any time regardless of cancer type, stage and treatment\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eExercise rehabilitation can be safely\u0026nbsp;initiated\u0026nbsp;at any time regardless of cancer type, stage and treatment, provided individualised patient screening has been conducted by a trained exercise professional\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformation about exercise rehabilitation should be provided in the first consultation when a person receives their diagnosis of cancer\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eInformation about exercise rehabilitation should be introduced at the first consultation (at the time of, or\u0026nbsp;immediately\u0026nbsp;following, diagnosis),\u0026nbsp;provided that\u0026nbsp;it can be done sensitively and with\u0026nbsp;due consideration\u0026nbsp;to the capacity of the patient to receive information\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformation about exercise rehabilitation should be initiated in the same consultation when a person receives information about their medical treatment\u003c/p\u003e \u003cp\u003eRound 2: \u0026nbsp;\u003cb\u003eInformation about exercise rehabilitation should be integrated into any medical consultation in which a person receives information about their medical treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformation and referral to exercise rehabilitation may need to be delayed for a person with advanced cancer receiving complex medical or palliative treatment\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eInformation and/or referral to exercise rehabilitation should be\u0026nbsp;initiated\u0026nbsp;as early as possible for a person with advanced cancer receiving complex medical or palliative treatment,\u0026nbsp;as long as\u0026nbsp;advice is tailored to individual patient needs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.5 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferral to exercise rehabilitation should be initiated in the first consultation when a person receives their diagnosis of cancer\u003c/p\u003e \u003cp\u003eRound 2: Everyone should be referred to exercise rehabilitation during the first medical consultation when a person receives their diagnosis of cancer\u003c/p\u003e \u003cp\u003eRound 3: \u003cb\u003eIt is appropriate to refer a person to exercise rehabilitation during the first medical consultation (at the time of, or immediately following, diagnosis)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferral to exercise rehabilitation should be initiated in the same consultation when a person receives information about their medical treatment\u003c/p\u003e \u003cp\u003eRound 2: Everyone should be referred to exercise rehabilitation during medical consultations when a person receives information about medical treatment\u003c/p\u003e \u003cp\u003eRound 3: \u003cb\u003eEveryone should be offered a referral to exercise rehabilitation during medical consultations when a person receives information about medical treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e90.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eLevel of Agreement (%): No. of participants who rated moderately agree to strongly agree (%), Red \u0026ndash; Did not achieve\u0026thinsp;\u0026ge;\u0026thinsp;80% consensus, statement was retained to be ranked again in next survey round, green \u0026ndash; Achieved\u0026thinsp;\u0026ge;\u0026thinsp;80% consensus, statement was removed from subsequent survey rounds.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDelphi survey results: factors related to cancer treatment.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRound 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eRound 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eRound 3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatements that underwent rating, n\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation can be\u0026nbsp;safely initiated at any time, regardless of cancer treatment, as long as the person is medically stable\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should only be initiated after a person has completed their cancer treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.5\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFor people undergoing major cancer surgery (e.g. abdominal resection, open lung surgery, mastectomy, radical prostatectomy), exercise rehabilitation should always be offered prior to surgery as long as a person is medically stable\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should only be initiated after a person has completed cancer surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.8\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should only be provided from midway through active cancer treatment (e.g. after a few cycles of chemotherapy, radiotherapy, immunotherapy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87.8\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should only be provided after a person has completed active treatment (e.g. chemotherapy, radiotherapy, immunotherapy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.4\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should only be provided to people with cancer after they have commenced maintenance therapy (e.g. hormone replacement or endocrine therapy for breast cancer)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should be initiated for people only if they have a low level of symptom burden (fatigue, pain, nausea)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should be initiated only when people have low levels of fatigue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.5\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeople who are receiving palliative care should not initiate exercise rehabilitation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.4\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhen a person is receiving palliative care, exercise rehabilitation should be initiated as early as possible within the context of their needs and fluctuations in health status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise rehabilitation should be initiated prior to commencement of any cancer treatment\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eHealth professionals should encourage people to\u0026nbsp;initiate\u0026nbsp;exercise rehabilitation prior to commencement of any cancer treatment, provided there is sufficient time leading up to treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor patients receiving non-surgical interventions, exercise rehabilitation should be initiated shortly after a person starts their cancer treatment (e.g. after 1st cycle of chemotherapy, radiotherapy, immunotherapy)\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eFor patients receiving non-surgical interventions, exercise rehabilitation should be\u0026nbsp;initiated\u0026nbsp;before rather than after a person starts their cancer treatment (e.g. before 1st cycle of chemotherapy, radiotherapy, immunotherapy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise rehabilitation should be initiated as soon as a person has reported any side effects (fatigue, neuropathy, cardiac dysfunction)\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eExercise rehabilitation should only be\u0026nbsp;initiated\u0026nbsp;if a person reports any side effects (fatigue, neuropathy, cardiac dysfunction) from cancer treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.3 disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise rehabilitation should be initiated only after serious medical complications (febrile neutropaenia, severe fatigue) have resolved\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eExercise rehabilitation may need to be delayed if a patient has serious medical complications (febrile neutropaenia, deep vein thrombosis)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise rehabilitation should be delayed for people who have high levels of symptom burden (fatigue, pain, nausea)\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eExercise rehabilitation should be initiated and modified accordingly for people who have high levels of symptom burden (fatigue, pain, nausea)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise rehabilitation should only be initiated prior to cancer surgery if a person has an expected window of \u0026ge;\u0026thinsp;4\u0026ndash;6 weeks from diagnosis to surgery\u003c/p\u003e \u003cp\u003eRound 2: Exercise rehabilitation should only be\u0026nbsp;initiated\u0026nbsp;prior to cancer surgery if a person is expected to have at least 2\u0026ndash;3 weeks to\u0026nbsp;participate\u0026nbsp;prior to surgery\u003c/p\u003e \u003cp\u003eRound 3: \u003cb\u003eExercise rehabilitation should be initiated prior to cancer surgery, regardless of the time a patient has from diagnosis to surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.6\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor people with haematological cancer, exercise rehabilitation should only be provided after a person has received their stem cell transplant and has been discharged from hospital\u003c/p\u003e \u003cp\u003eRound 2: For people with haematological cancer, exercise rehabilitation should be\u0026nbsp;initiated\u0026nbsp;before rather than after a person has received their stem cell transplant\u003c/p\u003e \u003cp\u003eRound 3: \u003cb\u003eFor people with haematological cancer, exercise rehabilitation should be initiated prior to their stem cell transplant, regardless of the time to transplant\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.3\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeople receiving end-of-life care should not initiate exercise rehabilitation\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRound 2: Structured exercise rehabilitation is not usually appropriate for people receiving end-of-life care, unless it is carefully adapted and desired by the person\u003c/p\u003e \u003cp\u003eRound 3: \u003cb\u003eExercise rehabilitation tailored to individual needs and goals is appropriate for people receiving end-of-life care\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.5\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e98.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should only be initiated if it is a priority for a person receiving end-of-life care\u003c/b\u003e\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003eFollowing Round 1, two statements\u003csup\u003ea,b\u003c/sup\u003e were combined to form one statement\u003csup\u003ec\u003c/sup\u003e.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eLevel of Agreement (%): No. of participants who rated moderately agree to strongly agree (%), Red \u0026ndash; Did not achieve\u0026thinsp;\u0026ge;\u0026thinsp;80% consensus, statement was retained to be ranked again in next survey round, green \u0026ndash; Achieved\u0026thinsp;\u0026ge;\u0026thinsp;80% consensus, statement was removed from subsequent survey rounds.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDelphi survey results: person-related factors.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRound 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eRound 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eRound 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatements that underwent rating, n\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIt is important to assess a person's physical and psychological readiness to determine whether they should start exercise rehabilitation earlier rather than later\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) only if a person is confident to exercise\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) only if a person is less confident to exercise\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eA flexible approach to the timing of exercise rehabilitation is required to support people who have competing priorities (medical appointments, work, family)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should be initiated earlier rather than later for a person with co-morbidities or complex health issues (cardiovascular disease, diabetes, osteoporosis etc.)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeople with decreased psychosocial support should be provided extra support by health professionals to start exercise rehabilitation earlier rather than later\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should be initiated only when a person has minimal or no competing priorities (e.g. medical appointments, work, family)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) only if a person has exercise experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.9\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) only if a person who has little or no experience with exercise\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.2\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA person with a culturally and linguistically diverse (CALD) or indigenous background should be provided extra support by health professionals to start exercise rehabilitation earlier rather than later\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eA person with a culturally and linguistically diverse (CALD) or indigenous background should be provided tailored support by health professionals to engage in exercise rehabilitation early\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA person with co-morbidities or complex health issues (cardiovascular disease, diabetes, osteoporosis etc) may need to delay their initiation of exercise rehabilitation\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eA person with co-morbidities or complex health issues (cardiovascular disease, diabetes, osteoporosis etc) may need to delay their initiation of exercise rehabilitation if they are not medically stable\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.5\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e86.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise rehabilitation should be initiated as early as possible (e.g. before or during treatment) only if a person is motivated to exercise\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eExercise rehabilitation should be\u0026nbsp;initiated\u0026nbsp;as early as possible (e.g. before or during treatment) regardless of the motivation of the person to exercise\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.9\u003c/p\u003e \u003cp\u003edisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise rehabilitation should be initiated as soon as a person feels physically ready to participate\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRound 3. \u003cb\u003eAn appointment to exercise rehabilitation should not be offered until a person feels physically and psychologically ready to participate\u003c/b\u003e\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e4 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation should be initiated as soon as a person feels psychologically ready to participate\u003c/b\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eFollowing Round 2, two statements\u003csup\u003ea,b\u003c/sup\u003e were combined to form one statement\u003csup\u003ec\u003c/sup\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA person's personal goals for recovery impact whether they start exercise rehabilitation earlier or later\u003c/p\u003e \u003cp\u003eRound 2: Starting exercise rehabilitation early depends on a person's personal goals for recovery\u003c/p\u003e \u003cp\u003eRound 3. \u003cb\u003eAn appointment to exercise rehabilitation should be offered only when a person has identified goals\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71.1 disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e2 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eLevel of Agreement (%): No. of participants who rated moderately agree to strongly agree (%), Red \u0026ndash; Did not achieve\u0026thinsp;\u0026ge;\u0026thinsp;80% consensus, statement was retained to be ranked again in next survey round, green \u0026ndash; Achieved\u0026thinsp;\u0026ge;\u0026thinsp;80% consensus, statement was removed from subsequent survey rounds.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDelphi survey results: health service-related factors.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRound 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eRound 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003eRound 3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatements that underwent rating, n\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u003cb\u003eLevel of Agreement (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eMedian Score (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation programs that are free, low-cost or offer financial hardship options support a person to initiate exercise rehabilitation earlier rather than later\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth services that are easily accessible (ample parking, convenient location, affordable or free parking) support people to initiate exercise rehabilitation earlier rather than later\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAccess to qualified exercise professionals co-located within a cancer treatment centre supports a person to initiate exercise rehabilitation earlier rather than later\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise rehabilitation offered via telehealth support people to initiate exercise rehabilitation earlier rather than later\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLong service waitlists delay the initiation of exercise rehabilitation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplex referral pathways delay the initiation of exercise rehabilitation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation and information on exercise rehabilitation provided by consumer advocacy groups is useful in promoting early referral to exercise rehabilitation services\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaving too many other medical appointments or medical appointments that clash with exercise rehabilitation session times prohibits people to start exercise rehabilitation\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eHaving too many other medical appointments or medical appointments that clash with exercise rehabilitation session times prohibits people to start exercise rehabilitation early\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnline resources such as exercise videos and apps support people to initiate exercise rehabilitation earlier rather than later\u003c/p\u003e \u003cp\u003eRound 2: \u003cb\u003eWhere patients have no access to exercise professionals, online resources such as evidence-based exercise videos or apps prepared by cancer exercise professionals can be used to support people to\u0026nbsp;initiate\u0026nbsp;exercise rehabilitation earlier rather than later\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHaving to travel to a different hospital or community gym outside of their main cancer treatment centre may delay a person's initiation of exercise rehabilitation\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eRound 2 (Refined into two statements\u003c/b\u003e\u003csup\u003e\u003cb\u003ea,b\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c9\" namest=\"c4\"\u003e \u003cp\u003eFollowing Round 1, statement was refined into two separate statements\u003csup\u003ea,b\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003cb\u003eHaving exercise rehabilitation co-located with medical cancer treatment centres\u0026nbsp;supports\u0026nbsp;a person to\u0026nbsp;initiate\u0026nbsp;exercise rehabilitation earlier rather than later\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e88.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003cb\u003eCommunity-based exercise rehabilitation may support a person to\u0026nbsp;initiate\u0026nbsp;exercise rehabilitation earlier rather than later\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e84.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eLevel of Agreement (%): No. of participants who rated moderately agree to strongly agree (%), Red \u0026ndash; Did not achieve\u0026thinsp;\u0026ge;\u0026thinsp;80% consensus, statement was retained to be ranked again in next survey round, green \u0026ndash; Achieved\u0026thinsp;\u0026ge;\u0026thinsp;80% consensus, statement was removed from subsequent survey rounds.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis modified Delphi study achieved international, multidisciplinary consensus on 54 statements to optimise the timing of exercise support in people with cancer. Engagement remained high across all rounds, with 83% of participants from Round 1 completing the final survey. Consensus highlighted four key findings: (i) exercise should be advised and offered as early as medically appropriate after a cancer diagnosis; (ii) a flexible, individualised approach is essential when starting exercise; (iii) discussion about exercise and referral to support services should be embedded within routine medical consultations; and (iv) system-level infrastructure is needed to facilitate timely access to exercise. The consensus achieved in this study reinforces current position statements recommending the integration of exercise as part of standard cancer care [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and further strengthens the evidence by explicitly stating that exercise should be implemented as an early, proactive component of care rather than as a reactive intervention.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eStarting exercise following a cancer diagnosis should be proactive rather than reactive. This aligns with the principles of prehabilitation, where exercise is prescribed prior to medical treatment such as surgery and chemotherapy with the aim of optimising health outcomes, post-treatment recovery and mitigating functional decline [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Emerging evidence demonstrates that even brief pre-operative exercise interventions, two to three weeks in duration, can improve functional capacity, postoperative recovery [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and contribute to a significant reduction in hospital length of stay [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] while demonstrating cost effectiveness [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This approach has continued to gain traction with peak professional health bodies recommending exercise as part of standard care in clinical practice guidelines [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, early exercise commencement in real-world settings must account for each patient\u0026rsquo;s circumstances such as readiness, symptom burden, psychosocial context, and competing demands, reflecting the heterogeneity of disease and treatment trajectories especially in the context of comorbidity and people from diverse backgrounds.\u003c/p\u003e \u003cp\u003eAll treating clinicians should reinforce and offer regular exercise advice and facilitate referral within routine clinical consultations and at key milestones. Patients may often be unsure and feel unprepared to start exercise but rather than waiting for patients to be ready [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], clinicians may find value in using an exercise consultation as an opportunity to improve a patient\u0026rsquo;s self-efficacy and facilitate behaviour change. Previous research has shown that when exercise is endorsed by oncologists and integrated into treatment discussions, referral rates and program adherence improve [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Yet these expectations contrast with current practice, where time pressures, competing clinical priorities, workplace culture, variable clinician confidence, and limited access to cancer exercise programs often result in ad-hoc or delayed referrals [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Without system-level structures to standardise follow-up and review, exercise pathways remain dependent on individual clinicians, producing inconsistent and inequitable implementation.\u003c/p\u003e \u003cp\u003eHaving the right systems, services, and support structures in place is crucial to help cancer patients start exercising early as part of their care. The expert statements in this study reflect challenges in implementation across both the inner and outer settings of the Consolidated Framework for Implementation Research (CFIR) framework [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Experts identified inner-setting barriers such as complex referral pathways, long waitlists, and insufficient access to qualified exercise professionals, all of which contribute to fragmented implementation and delayed engagement. Barriers across the outer setting including workforce shortages, funding constraints and lack of programs further increase inequities in access. Enablers included accessible and affordable programs and health professionals with expertise in exercise, co-located exercise services within cancer treatment centres [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] and community-based or telehealth models [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], reflecting previous findings that addressing logistical and financial barriers improves engagement [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In settings where cancer exercise services are unavailable, online resources and consumer advocacy groups were viewed as valuable outer-setting supports that can promote early engagement. These findings provide expert direction for health professionals on implementing exercise guidelines in cancer care and support clinicians in delivering timely, consistent, and person-centred exercise interventions. By addressing when and how exercise should be offered, alongside the infrastructure, resources, and system-level supports required for implementation, the findings align with the AGREE II applicability domain, which emphasises the practical translation of recommendations into clinical practice [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eWe included a large, multidisciplinary, international expert panel of health professionals with clinical, research and health administrative experience in exercise for people with cancer. Statements were created in an iterative, collaborative process between clinicians, researchers and consumers. High retention rates across three rounds (83%) and strong engagement with open-ended feedback further strengthens confidence in the reliability of the consensus.\u003c/p\u003e \u003cp\u003eDespite multidisciplinary participation, representation from medical specialists such as oncologists and surgeons was limited. This is important as medical specialists can influence patient behaviour and have early conversations with patients where exercise can be discussed and recommended. This was balanced by strong representation from professionals who are viewed by the cancer care team as experts in exercise. While consumers were included in the initial stakeholder workshop and development of survey statements, the exclusion of consumers from the Delphi rounds may have limited insight into the perspectives and lived experiences of people with cancer. Future research should explore the perspectives of patients on the factors influencing the optimal timing of starting exercise following cancer.\u003c/p\u003e \u003cp\u003eThe number and range of open-ended feedback provided across all survey rounds reflects strong professional engagement and recognition of the importance of exercise timing. While detailed feedback was incorporated into subsequent survey statements using standardised methods, some specificity may have been lost. The online survey platform ensured participant anonymity and convenience but limited the opportunities for collaborative discussion with participants.\u003c/p\u003e \u003cp\u003eWhile grounded in expert consensus, the impact of strategies identified in this study on improving outcomes for people with cancer remains unknown. A key next step will be to evaluate these consensus-informed strategies in clinical trials to determine whether their implementation improves access and translates into better outcomes for people with cancer.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides expert consensus that exercise should be started as early as medically appropriate after cancer diagnosis, with exercise discussion and referral embedded into routine oncology consultations, and tailored to each patient\u0026rsquo;s health status, needs and readiness. These findings provide a practical framework to guide the development of timely, person-centred exercise pathways and offer guidance on implementing broad position statement recommendations into clinical practice [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Germaine A Tan is supported by the La Trobe University and NHMRC Graduate Researcher Scholarship (Grant #2031419).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Germaine A Tan, Casey L Peiris, Nicholas F Taylor, Katherine E Harding and Amy M Dennett. The first draft of the manuscript was written by Germaine A Tan and all authors reviewed and drafted previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the La Trobe University Human Research Ethics Committee (Approval Ref No. HEC25054).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from this study are available from the corresponding author on reasonable request and following appropriate ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u003c/strong\u003eThe authors would like to thank all participants for their valuable comments and their contribution to this study. The authors also thank our Steering Committee for participating in our initial stakeholder workshop and pilot testing of surveys.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCourneya KS, Vardy JL, O'Callaghan CJ, et al. Structured Exercise after Adjuvant Chemotherapy for Colon Cancer. N Engl J Med. 2025;393(1):13\u0026ndash;25. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa2502760\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa2502760\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCormie P, Zopf EM, Zhang X, et al. The Impact of Exercise on Cancer Mortality, Recurrence, and Treatment-Related Adverse Effects. 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Quality of Rehabilitation Clinical Practice Guidelines: An Overview Study of AGREE II Appraisals. Archives of Physical Medicine and Rehabilitation. 2020;101(9):1643\u0026ndash;55. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.apmr.2020.03.022\u003c/span\u003e\u003cspan address=\"10.1016/j.apmr.2020.03.022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cancer, exercise, rehabilitation, timing","lastPublishedDoi":"10.21203/rs.3.rs-8846045/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8846045/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eExercise has benefits before, during and after cancer treatment. However, the optimal timing of when to start exercise remains unclear. This study aimed to establish expert consensus on the optimal timing for starting exercise following a cancer diagnosis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e This modified Delphi study followed Conducting and Reporting Delphi Studies guidelines to establish expert consensus. A steering committee of oncology clinicians, researchers and people with cancer developed initial survey statements addressing disease-, treatment-, person- and health service-related factors that may influence exercise initiation. A three-round modified electronic Delphi process was conducted to 1) collect expert opinions, 2) analyse emerging themes, and 3) refine statements for ranking on a 9-point Likert scale (1\u0026thinsp;=\u0026thinsp;Strongly Disagree to 9\u0026thinsp;=\u0026thinsp;Strongly Agree). Statements achieving\u0026thinsp;\u0026ge;\u0026thinsp;80% consensus were retained.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEighty oncology experts from five continents participated in Round 1, with retention rates of 80% and 77% in Rounds 2 and 3, respectively. By Round 3, consensus was reached on 54 of 57 statements. The consensus statements highlighted the importance of starting exercise early following diagnosis, ideally before treatment, but tailoring timing of interventions to individual needs. Embedding discussions about exercise into routine oncology consultations and system-level supports were identified as key to ensuring timely access.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study provides expert consensus supporting early, individualised exercise prescription and support following cancer diagnosis. These findings offer a foundational framework to guide the development of timely, person-centred exercise models aimed at optimising health outcomes for people with cancer.\u003c/p\u003e","manuscriptTitle":"When is the best time to start exercise after a cancer diagnosis? A modified Delphi consensus study of expert health professionals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-17 13:10:44","doi":"10.21203/rs.3.rs-8846045/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"24642177303396445252921674673009182965","date":"2026-05-05T03:34:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"293665500251273224626038131871557720574","date":"2026-03-16T00:01:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-15T19:59:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-15T19:58:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-13T04:34:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2026-02-11T01:30:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"fe0dc869-a5cd-4d27-830b-7e8a70ab2648","owner":[],"postedDate":"March 17th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"24642177303396445252921674673009182965","date":"2026-05-05T03:34:38+00:00","index":21,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-17T13:10:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-17 13:10:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8846045","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8846045","identity":"rs-8846045","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}