key: cord-0992570-ldgk8jcs authors: Gonzalo-Encabo, Paola; Wilson, Rebekah L.; Kang, Dong-Woo; Normann, Amber J.; Dieli-Conwright, Christina M. title: Exercise oncology during and beyond the COVID-19 pandemic: are virtually supervised exercise interventions a sustainable alternative? date: 2022-05-05 journal: Crit Rev Oncol Hematol DOI: 10.1016/j.critrevonc.2022.103699 sha: 2e6d8ca4cf8b51051d485fc5609402a397255759 doc_id: 992570 cord_uid: ldgk8jcs During the COVID-19 pandemic, new challenges are presented in clinical research settings to increase exercise levels, particularly in vulnerable populations such as cancer survivors. While in-person supervised exercise is an effective format to improve patient-reported outcomes and physical function for cancer survivors, the COVID-19 pandemic limited this form of exercise as a feasible option within research and cancer care. As such, exercise oncology interventions were adapted to home-based instruction. In this review, we examine the current evidence of exercise interventions in cancer populations during and beyond the COVID-19 pandemic. We identified that group-based virtually supervised home-based exercise was the most used format among exercise oncology interventions during the pandemic. Preliminary results support feasibility and effectiveness of this emerging exercise setting in cancer survivors; however, it needs to be further investigated in adequately designed larger trials. Additionally, we provide recommendations and perspective for the implementation of virtually supervised home-based exercise. The novel coronavirus (SARS-CoV-2 or COVID- 19) is an unprecedented public health challenge that affected the entire world with several high impact changes in daily life and was classified as a global pandemic by the World Health Organization on March 11 th of 2020. 1 Prior to COVID-19, physical inactivity was considered a major public health concern 2 and recognized as a global pandemic. 3 This lack of physical activity was further exacerbated by the implementation of COVID-19-related "stay at home" mandates with increases in sedentary behavior seen worldwide. 4, 5 In this regard, new challenges are presented in clinical and research settings to increase physical activity and exercise levels. 6, 7 This is especially difficult in clinical populations such as cancer survivors, who are highly susceptible to infection and at risk for severe illness from COVID- 19, 8 due to the nature of disease development at an older age as well as the immunosuppressive state caused by cancer and its treatments. 9 Exercise is a critical adjuvant therapy for cancer survivors and has been shown to improve cancer and treatment-related outcomes (e.g., patient-reported outcomes and physical function). 10 However, most cancer survivors were already insufficiently active prior to the COVID-19 pandemic, 11 and "stay at home" mandates have resulted in further activity declines. 12 In terms of exercise interventions in research, in-person supervised exercise programs are more effective in improving cancer-and treatment-related side effects than self-directed, home-based interventions. [13] [14] [15] Given that most individuals living with cancer report a preference for exercising at home, 16 integrating virtual supervision (e.g., telehealth) may be a potential tool for improving home-based exercise programs. 17 During the pandemic, several clinical trials in exercise oncology transitioned their interventions from supervised to home-based or were J o u r n a l P r e -p r o o f postponed/terminated. 18 Consequently, researchers and clinicians had the opportunity to examine different home-based exercise programs to overcome barriers to engage cancer survivors in exercise during COVID-19. To our knowledge, this is the first review that aims to investigate different exercise interventions and discuss potential effectiveness in cancer survivors before, during, and beyond COVID-19. We provide recommendations for designing effective supervised home-based exercise interventions post-pandemic for cancer survivors. Furthermore, we discuss the challenges and perspectives for exercise oncology clinical trials beyond COVID-19. We conducted a systematic search using PubMed, Google Scholar and Web of Science databases for published studies and conference abstracts until January 2022. Search terms included various combinations of: COVID-19; oncology; exercise. The key criterion was to identify clinical exercise oncology studies during COVID-19 pandemic. Furthermore, randomized and non-randomized clinical trials, single-arm studies, case series and cohort studies were included if they involved an exercise/physical activity component. Extracted data included the first author's name, year of publication, population (e.g., sex, cancer type, stage, age, minorities), study design, intervention period, exercise prescription, adherence and results. Twelve published studies met our inclusion criteria and were included in this review. Given the heterogeneity of studies, a narrative review was chosen to discuss a wider array of studies and provide a more complete critical perspective. Exercise should be tailored to the targeted patient group, cancer type, treatment, and outcome of interest; however, the delivery of exercise interventions is also of high importance J o u r n a l P r e -p r o o f (Table 1 ) and may be dictated by the needs of the patient. The superior effect of supervised exercise compared to unsupervised exercise may be attributed to a real-time, face-to-face environment. Supervised exercise ensures that the exercise selection, technique, and intensities are adhered to and appropriately prescribed to promote the desired physiological adaptations in the patient. 14 Supervised exercise also promotes safety, which is particularly important for survivors on treatment as their physical and mental health status can change daily due to the acute side effects. 19 With the establishment of in-person supervised exercise as a feasible and safe adjuvant therapy, 13, 20-23 research examining self-directed, home-based exercise interventions were growing in popularity within the exercise oncology paradigm prior to COVID-19. 24-26 Selfdirected, home-based exercise can take many forms as highlighted in Table 1 . The everdeveloping technology industry, smart watches, phones, exercise equipment, tablets, and websites allow immediate access to exercise programs and analysis of personal fitness and activity levels. While these platforms are effective at improving fitness and activity levels for cancer survivors, 27 compared to in-person supervised exercise, self-directed home-based exercise only induces smaller desirable changes in the outcome of interest. 28 Patients may not be able to gain the full potential benefits of exercise without the supervision of an exercise professional, since an understanding of how to prescribe exercise, adapt the prescription to daily physiological changes or injuries, and interpretation of the data gained from technology used (e.g., using smart watch heart rate to meet a certain intensity), is required to induce substantial beneficial changes in the targeted outcome of interest. J o u r n a l P r e -p r o o f During the COVID-19 pandemic, many different approaches were taken on how to develop 33 or adapt 29-39 new or existing studies and clinic-based programs including self-directed unsupervised (e.g. booklet of exercise recommendations), self-directed with regular guidance (e.g., weekly phone calls with exercise trainer), and supervised (e.g., virtual live exercise). Here we describe key exercise oncology-based studies during COVID-19 (Table 2) . We identified two studies that reported the use of self-directed unsupervised interventions that were adapted to COVID-19 restrictions. 36, 40 López-Rodríguez-Arias et al. 36 examined the effect of a home-based prehabilitation program on body composition in 20 patients scheduled for colorectal surgery. Patients were recommended to complete daily exercise by following a 30-45 minute aerobic and resistance exercise video. They reported that prehabilitation attenuated loss of lean mass and stabilized weight and fat mass as well as reduced the length of hospitalization. Yildiz Kabak et al. 40 examined hematopoietic stem cell transplant patients and their compliance to a home-based exercise program that was prescribed prior to the COVID-19 "stay at home" period. Compliance to exercise during this period was negatively associated with age, performance status, and symptom score, and positively associated with functionality and general health scores. However, exercise compliance significantly deteriorated during the "stay at home" period where only 13.3% stated they regularly performed the prescribed exercise; in contrast with 56% self-reporting compliance in a similar study conducted in the same clinic pre-COVID- 19. 41 As highlighted above, adherence continue to be a challenge in unsupervised home-based exercise interventions even during the COVID-19 pandemic among cancer patients. The understanding of why patients do and do not adhere to exercise, as well as the needs of different J o u r n a l P r e -p r o o f populations e.g., older and frail versus young and fit, will assist in the development of strategies to improve home-based exercise adherence. For example, the inclusion of supervised homebased exercise may be of benefit and provide a point of accountability for patients at home. Nevertheless, these preliminary results in colorectal patients support the effectiveness of selfdirected unsupervised home-based exercise interventions. We identified four studies examining self-directed exercise/physical activity and lifestyle interventions with regular guidance. Overall, these studies used websites with online videos, 38 smartwatches (e.g., fitbit) 42 and printed exercise materials to support cancer survivors with lifestyle and exercise resources during COVID-19, as well as phone calls or messages to maintain weekly contact with patients. [37] [38] [39] 42 For example, Papandreou et al. 37 conducted a 3month RCT in 44 breast cancer survivors to assess the impact of an adapted clinical resource (e.g. implementation of a patient food database as part of the Clinical Decision Support System [CDSS] to assist in clinical decision making for care of cancer survivors), which was complemented by phone calls every 15 days to assist with the implementation of Mediterranean diet and physical activity consultation. They reported that those exposed to the CDSS had a significantly increased adherence to the Mediterranean diet, increased physical activity levels, achieved weight and fat mass loss, and maintained glucose and lipid levels when compared to the control group who only received phone calls to discuss general lifestyle advice every 15 days. Wu et al. 38 also completed a prospective observational study to assess the feasibility of their COVID-19 adapted prehabilitation program for cancer survivors from in-person to homebased which included educational material, online videos, and weekly contact from staff who reinforced healthy lifestyle behaviors. The adapted prehabilitation program was well received J o u r n a l P r e -p r o o f with 76% of patients consenting to participate; reasons for non-acceptance included selfperceived lack of benefit, starting treatment soon, or wanted face-to-face program. Focus groups highlighted benefits of the adapted program to include flexibility, accessibility, social support from staff, and eliminating the need to exercise in front of others, therefore, removing the perceived judgement of other exercisers. Contrastingly, identified challenges included lack of digital ability and literacy, potential cost of digital resources, absence of group sessions, and reliance on self-motivation. Nevertheless, the adapted prehabilitation program led to significant improvement in self-perceived health and fatigue. Nataluci et al. 39 originally proposed a combined home-based and in-person exercise and nutrition protocol, which was completed for 4-weeks before COVID-19 "stay at home" mandates. All sessions became home-based with weekly phone calls from exercise and nutrition specialists to reinforce advice and recommendations. Due to the change in intervention, the control and intervention groups were combined for analysis as the control group also received weekly healthy lifestyle reminders and a preliminary analysis indicated no difference between groups. They reported that weekly healthy lifestyle reminders during the COVID-19 "stay at home" period led to improved BMI, cardiorespiratory fitness, metabolic and inflammatory parameters, cardiac function indexes, heart rate variability, and Mediterranean diet adherence. Other researchers found similar positive impacts of adapted exercise interventions as a result of COVID-19 "stay at home" mandates. 42 In this regard, home-based self-directed exercise with regular guidance from support staff (e.g., research or clinical people) during the COVID-19 pandemic was feasible in cancer patients and led to improved lifestyle behaviours (e.g., increases in physical activity), as well as health outcomes such as body composition and VO2max. Another major adaptation that occurred because of COVID-19 was the implementation of virtually supervised exercise as an alternative to supervised in-person sessions. We identified seven manuscripts that reported the use of virtually supervised or video-conferencing format as an alternative modality of exercise intervention delivery during COVID-19. [29] [30] [31] [32] [33] [34] [35] Overall, various computer or smartphone applications were used (e.g., Zoom, FaceTime, Skype, or WhatsApp) and exercise sessions were mostly conducted in a group-based setting rather than a one-on-one. There are substantial heterogeneities across studies in terms of study designs (e.g., single-arm), sample sizes (e.g., ranging n=2 to 491), and cancer types (e.g., breast, prostate). Furthermore, most of the studies were not designed for assessing virtual exercise and analyzed a sub-sample of participants who received virtual exercise as an alternative during COVID-19. 29, 30, 33-35 However, the findings suggest that virtually supervised exercise is generally feasible and well-accepted in cancer survivors, with adherence ranging from 84.0% to 94.4%. 29-35 Winters-Stone et al. 33 analyzed data from two individual trials in 62 breast cancer survivors and spouses and 32 prostate cancer survivors to report the feasibility of virtually supervised exercise. Compared to in-person supervision before COVID-19, virtually supervised format showed higher rates of attendance in both interventions (80-81% vs 86-91%, respectively) and retention (80-81% vs 91-95%, respectively). 33 Wonders at al. 34 It should be noted that these trials were not initially designed to examine the feasibility and efficacy of virtually supervised exercise, where the findings were likely confounded due to the mixed use of in-person and virtual formats given the timeframe of the intervention periods and sudden changes in COVID-19 related restrictions. Nevertheless, the use of virtually supervised exercise is deemed feasible in cancer survivors and potentially efficacious in improving physical fitness and patient-reported outcomes, which requires further research designed to utilize this format and to examine its feasibility, acceptability, and effectiveness in various cancer settings. Given emerging COVID-19 variants and the continuous increase in cases worldwide, 48 it is likely that virtual exercise oncology will continue to grow. As summarized in Table 3 , J o u r n a l P r e -p r o o f virtually supervised exercise has several advantages including the use of a hygienic space, elimination of mask-wearing, and removal of travel burden to exercise facility. Moreover, the virtually supervised format allows researchers to maintain the rigor and fidelity of supervised exercise in a remote setting. However, several challenges must be overcome such as technology illiteracy, securing a large, safe, and uninterrupted space if a patient lives with others, cost of equipment including Wi-Fi, and patient safety, particularly if a patient has never exercised before, has comorbidities, or treatment-related side effects. With these advantages and challenges in mind, and the preliminary results of virtually supervised exercise previously discussed, we present recommendations for researchers and exercise professionals for delivering virtually supervised home-based exercise interventions for cancer survivors. Researchers should consider various strategies to ensure patients' safety throughout each virtual exercise session. One-on-one exercise sessions are a crucial aspect to ensure safety in a virtual setting, especially when working with a clinical population with no previous exercise experience. To ensure safety during group-based exercise sessions with cancer patients, it is important to have introductory sessions to ensure proper technique and reduce injury risk. Furthermore, given that cancer survivors often experience daily changes as a result of treatment side-effects, we recommend the use of a cancer-related symptom questionnaire (e.g., Therapy-Related Symptom Checklist) before each one-on-one exercise session to identify symptoms that should be closely monitored during exercise or even preclude the exercise session. 49 During a group-based exercise session, breakout rooms before the start of the exercise session could be used for this purpose to discuss health-related issues with each individual in a private space. Moreover, exercise trainers and researchers need to confirm the address where patients are J o u r n a l P r e -p r o o f training remotely, as well as having an emergency contact and knowing if the patient is home alone, in case any accident occur during the exercise session. Additionally, heart rate (HR) monitors and automated blood pressure measures can be used to conduct health screening before exercise and monitor HR during exercise, particularly patients with cardiometabolic comorbidities. 50 It is also ideal to conduct an initial in-person exercise familiarization session to provide patients with detailed exercise instructions (e.g., proper exercise postures and use of exercise equipment), especially with older cancer survivors or those with comorbidities (e.g., severe osteoporosis, neuropathy, etc.). Lastly, it is important to include in the consent form potential liability issues (e.g., if the exercise equipment damages the floor at patient's house) and data protection issues (e.g., apps use, sharing their personal address with the exercise equipment company for delivery, etc.). A virtually supervised intervention may provide a greater opportunity to adequately meet the intended exercise prescription compared with unsupervised interventions, 51 but there are several points to consider. Virtually supervised home-based exercise interventions in cancer survivors should be developed using the Frequency, Intensity, Time, Type (FITT) principles and exercise volume to ensure a proper exercise prescription, and to provide better context for interpreting study results and improve research to practice translation. 52 Regarding exercise modality, aerobic exercise may be simpler to implement as modes such as walking are natural for majority of people, therefore, little guidance is required to teach the exercise mode. However, if aerobic exercise equipment is utilized (e.g., stationary bike, rower etc.) this can add several challenges and barriers including high cost, assembly of equipment if delivered in parts, and exercise technique on devices that may be unfamiliar to the participant. With regard to resistance J o u r n a l P r e -p r o o f exercise, the equipment cost may be lower (e.g., resistance bands, body weight exercise, etc.), than aerobic equipment (e.g., treadmill); however, the verbal instruction of resistance exercise technique may be more challenging in a virtual environment compared to an in-person environment where physical corrections are possible. Moreover, it should be noted that trainers and researchers require an appropriate visual of the patient throughout the session to reduce injury risk and monitor proper technique in the use of weight machine alternatives. 53 Although increases in muscle mass and strength have been previously reported using home-based interventions in certain populations such as older adults, 54 typically home-based resistance exercise is mostly limited to free weights, resistance bands, or body weight. While these resistance-based modes are effective and can elicit muscle mass and strength improvements, 55 participants may not be able to achieve the same intensity needed to induce proportional improvements when compared to clinic-based programs utilizing machine-based weights. Furthermore, adaptations in muscle mass and strength can be difficult to induce in cancer patients, regardless of resistance training mode, given the effects of cancer, its treatment, and presence of comorbidities. 43 Therefore, it is important to consider if the training objective (e.g., strength or hypertrophy) is feasible in a home-based setting where equipment and space limitations may be present. Furthermore, prescribing the desired exercise intensity, is a key training variable that should be manipulated accordingly during virtual supervision. For example, treatment side effects may affect HR resulting in tachycardia or bradycardia, so we recommend using %HRmax or %HR reserve in combination with additional methods such as watt-based training prescription, rating of perceived exertion (RPE), or the Talk Test, to gauge intensity to ensure the appropriate dosage. 56, 57 Effective resistance training prescriptions include using the percentage of repetition maximum (%RM) after in-person testing combined with other methods J o u r n a l P r e -p r o o f such as the perceived exertion scale for resistance exercise (Omni-res scale) 58 or the number of repetitions in reserve (RIR). 59 Researchers should include frequent strength and cardiovascular testing timepoints for cancer survivors in order to meet training principles (e.g. progression or overload). 52 Recognizing the diverse environments and available amenities that compromise the efficacy of home-based exercise provides important insight for designing exercise prescriptions. One of the most reported challenges by cancer survivors in home-based exercise interventions is establishing suitable space for training (i.e. create a spacious area to exercise, appropriate and safe anchor of exercise bands, etc.). 24 Additional barriers include unsafe neighborhoods or possible interruptions during exercise sessions from cohabitants. 60 Therefore, it is important to identify home-based barriers to exercise training during baseline assessments and provide alternate options that are safe with adequate space (i.e. outdoor park settings). 24 Cancer survivors may also experience accessibility barriers (e.g. poor technology literacy, unstable Wi-Fi, programs or websites not formatted for use on mobile phone/tablet). 61 Researchers should consider providing patients with detailed written instructions on device function, connecting to video conferencing, and securing stable internet access (e.g., providing internet-enabled tablet). Encouraging patients to test their internet connection prior to training sessions could alleviate the disruptive and frustrating nature of internet reliability. Adherence is a challenge in exercise oncology trials and can be improved through many facets, with primary consideration for providing flexible scheduling options to accommodate patient availability for training at home and to address possible technology delays that require rescheduling exercise sessions. Additionally, trainer education should be standardized to conduct J o u r n a l P r e -p r o o f virtual exercise sessions comparable to in-person sessions, and include the type/frequency of verbal feedback, provide adequate motivation while exercise is being performed, and assess patient's status/progress throughout the session (e.g., Borg scale or HR). Furthermore, integrating group-based sessions with other cancer survivors can enhance social interaction and potentially benefit intervention adherence and motivation. Delivering remote exercise testing to prescribe exercise and to assess health outcomes in cancer survivors is also a great challenge, with limited evidence regarding the validity to adapt in-person to remote assessments. Winters-Stone et al. 62 In this regard, ensuring safety and validity during a remote assessment of cardiorespiratory fitness may be more difficult, particularly for older adults or those with comorbidities. For example, preliminary data suggest adequate validity for the 6-minute walk test (6MWT) when performed outdoors independently monitored with phone applications, but not in a home-based setting, and may be a simple virtual indirect alternative to the in-clinic cardiopulmonary exercise test (CPET). 63 Overall, there is insufficient evidence to ensure the validity of virtually supervised remote exercise testing in cancer survivors, therefore we recommend striving for in-person exercise testing in order to accurately prescribe exercise and ensure valid measurements of health outcomes. Formalizing these types of recommendations for continuity of exercise-based research during a pandemic are essential to deliver effective virtual-based interventions that promote safety, proper prescription and testing, accessibility, and adherence for cancer survivors. The COVID-19 pandemic has led to the significant emergence and integration of virtually supervised home-based exercise interventions within clinical research among cancer survivors. This approach allows us to take advantage of both at-home and in-person exercise. Emerging studies included in this review have shown feasibility and safety of virtually supervised home-based exercise interventions among cancer survivors, and improvements in several health outcomes (e.g., fatigue or quality of life). However, given the relatively recent nature of COVID-19, there is insufficient evidence supporting the effectiveness of this approach on other important cancer-related health outcomes such as body composition, physical function, or clinical outcomes (e.g., survivorship). Moving beyond the pandemic, it is probable that in the upcoming years several exercise oncology trials will be delivered remotely. We believe that these trials should implement a virtually supervised design to maximize health benefits. Before transitioning to a remote environment, it is important to consider the cost-benefit ratio of a virtually supervised homebased exercise intervention compared to in-person as the former may present additional financial challenges for the research team that could be underestimated. Furthermore, there is a need to reflect on the future progression of exercise oncology research and which outcomes or exercise interventions need to be tested in person first. These preliminary studies will provide evidence for which interventions should and should not be delivered virtually to derive the most effective J o u r n a l P r e -p r o o f and safe exercise prescriptions for home-based use. For example, can important health outcomes for cancer patients (e.g., muscle mass, bone health) be improved long-term with a virtually supervised home-based approach? Is home-based exercise equipment able to provide a sufficient anabolic stimulus? Can high-intensity interval training be delivered safely at home? In this regard, there are several questions that are unsolved in a remote exercise setting, thus future trials in exercise oncology using this approach are needed. Virtually supervised exercise can reduce barriers to participation in an in-person exercise intervention in cancer patients living in rural communities, countries with long distances, or countries with weak fitness facilities infrastructure reduce barriers to access to exercise facilities in rural communities or countries with long distance or weak fitness facilities infrastructure. 64 Moreover, this pandemic has led to a dramatic impact in racial/ethnic minority cancer survivors, with an increase in health inequalities and socio-economic disparities. 65, 66 Therefore, barriers to enrolling in exercise oncology trials during and after the pandemic may be even greater for more vulnerable populations 67 including older adults or those from racial/ethnic minority backgrounds. Furthermore, current data reveals that racial and ethnic minority cancer survivors experienced a higher burden to access telehealth tools. 68 Regarding remote exercise interventions, it is unknown yet if technology may eliminate or exacerbate barriers to exercise in this population. Our research laboratory is currently evaluating this with multiple ongoing studies including the ROSA trial, 69 which targets Latina and/or Hispanic breast cancer survivors and the THRIVE trial 70 which targets Black and Hispanic cancer survivors receiving chemotherapy. The ROSA trial transitioned to a Zoom-based supervised exercise intervention due to the pandemic. We have implemented several strategies to ensure that remote exercise does not increase barriers to exercise in this population (i.e., providing a Wi-Fi-enabled tablet, training equipment). Results J o u r n a l P r e -p r o o f from this ongoing trial will allow determining the effectiveness of this new exercise approach in important health outcomes (i.e., metabolic dysregulation, body composition), and if it reduces barriers to participation in exercise trials in this specific population. The THRIVE trial was designed to include a virtual exercise intervention from inception to outreach to patients not residing within the Greater Boston area or that lack adequate transportation for clinical in-person exercise. Collectively these trials will aid in planning for future exercise oncology intervention for minority survivors. Following a review of the existing unsupervised, semi-supervised and virtually supervised exercise interventions in cancer survivors, we identify that virtually supervised groupbased exercise interventions were the most common format among oncology lifestyle interventions during the pandemic. We conclude that virtually supervised home-based exercise interventions may be feasible, safe, and may improve several health outcomes in cancer survivors (e.g., fatigue, anxiety/stress, etc.). Given these studies were not designed to test feasibility and efficacy of this exercise approach, future studies should be specifically designed and powered to further investigate these outcomes and other health and clinical outcomes such as body composition, physical function, or survivorship. Recommendations for future interventions using this exercise approach include ensuring safety, proper prescription and testing, accessibility, and adherence. While infection rates continue to grow due to new COVID-19 variants, it is critical to continue to encourage the uptake of exercise among cancer survivors, given the known benefits of exercise, as the risks associated with inactivity may result in additive or synergistic risks when coupled with the risk of infection from COVID-19. Therefore, during these challenging times, there is a need to maintain and develop high-quality research in exercise J o u r n a l P r e -p r o o f oncology to support cancer survivors to start and continue exercising beyond the COVID-19 pandemic. Martinez-Ferran M, de la Guia-Galipienso F, Sanchis-Gomar F, Pareja-Galeano H. https://reporter.nih.gov/search/bZRZEXqPhkicrkPy8WWHyw/project-details/10328010#details Table 1 . Settings for exercise and physical activity interventions in cancer survivors.  In-person, clinic-based (e.g., hospital run exercise facility with exercise oncology trainers).  In-person, one-on-one or group, community-based (e.g., gym personal trainer).  Virtual, one-on-one or group, home-based (e.g., exercise oncology trainer video conferences with patient in real time and provides exercise instruction). Self-directed with regular guidance  Weekly phone calls/texts/email with exercise trainer to check progress on completing exercise recommendations and make new exercise goals (e.g., trainer provides individual prescription for progress but does not supervise execution of exercise). Self-directed unsupervised  Home-based, surrounding neighborhood, or community facility/club (e.g., gym membership, sport club).  Web-based (e.g., follow exercise videos on YouTube).  Phone application-based (e.g., follow exercise programs provided through application).  Booklet/handout (e.g., booklet of exercise recommendations with instructions on how to perform them).  Wearable technology (e.g., using a smart watch to track step count and heart rate).  Exercise equipment with built in on-demand programs (e.g., Tonal, Peloton, Mirror). World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19) Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants The pandemic of physical inactivity: global action for public health Changes in physical activity and sedentary behaviours from before to during the COVID-19 pandemic lockdown: a systematic review Associations between individual and environmental determinants and physical activity levels of an active population during the Spanish lockdown Impact of the COVID-19 pandemic on clinical research Effects and moderators of exercise on quality of life and physical function in patients with cancer: An individual patient data meta-analysis of Clinical exercise interventions in prostate cancer patients--a systematic review of randomized controlled trials. Support Care Cancer Physical activity programming and counseling preferences among cancer survivors: a systematic review Exercising in Isolation? The Role of Telehealth in Exercise Oncology During the COVID-19 Pandemic and Beyond Keeping Patients With Cancer Exercising in the Age of COVID-19 Supervised exercise therapy compared with no exercise therapy to reverse debilitating effects of androgen deprivation therapy in patients with prostate cancer: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis Supervised Physical Rehabilitation in the Treatment of Patients with Advanced Cancer: a Systematic Review and Meta-analysis Effects of supervised exercise on motivational outcomes and longer-term behavior Effects of Supervised Multimodal Exercise Interventions on Cancer-Related Fatigue: Systematic Review and Meta-Analysis of Randomized Controlled Trials Variability and limitations in home-based exercise program descriptions in oncology: a scoping review. Support Care Cancer Home-based multidimensional survivorship programmes for breast cancer survivors. Cochrane Database Syst Rev Home-Based Aerobic and Resistance Exercise Interventions in Cancer Patients and Survivors: A Systematic Review. Cancers (Basel) Effect and feasibility of wearable physical activity trackers and pedometers for increasing physical activity and improving health outcomes in cancer survivors: A systematic review and meta-analysis Effectiveness of a resistance training program on physical function, muscle strength, and body composition in community-dwelling older adults receiving home care: a cluster-randomized controlled trial Aerobic Exercise-Induced Changes in Cardiorespiratory Fitness in Breast Cancer Patients Receiving Chemotherapy: A Systematic Review and Meta-Analysis. Cancers (Basel) Validity of the counting talk test in comparison with standard methods of estimating exercise intensity in young healthy adults Concurrent validation of the OMNI-Resistance Exercise Scale of perceived exertion with elastic bands in the elderly Novel Resistance Training-Specific Rating of Perceived Exertion Scale Measuring Repetitions in Reserve Physical activity in relation to urban environments in 14 cities worldwide: a cross-sectional study The Feasibility of Exercise Interventions Delivered via Telehealth for People Affected by Cancer: A Rapid Review of the Literature Converting Physical Function Testing to the Remote Setting: Adapting Our Research Protocol During COVID-19. presented at: GSA 2020 Annual Scientific Meeting Home-based or remote exercise testing in chronic respiratory disease, during the COVID-19 pandemic and beyond: A rapid review Challenges of Rural Cancer Care in the United States Analyses of risk, racial disparity, and outcomes among US patients with cancer and COVID-19 infection COVID-19 exacerbating inequalities in the US Implications for Physical Activity, Health Disparities, and Health Equity Patient-related barriers to some virtual healthcare services among cancer patients in the USA: a population-based study Reducing Metabolic Dysregulation in Obese Latina Breast Cancer Survivors Using Physical Activity Testing Homebased ExeRcise Strategies to Improve Exercise Participation and The authors would like to acknowledge the contribution of Danny Nguyen in the graphical abstract J o u r n a l P r e -p r o o f The authors of this paper declare no conflicts of interest.  Preliminary results suggest feasibility, safety, and effectiveness of virtually supervised exercise.  We provide recommendations and perspectives for the implementation of virtually supervised exercise in future exercise oncology trials.  There is a need to develop high-quality research in exercise oncology to support cancer survivors beyond the COVID-19 pandemic.