**3. Fitness assessment procedures**

After all necessary paperwork is complete and the physician's clearance has been signed and returned, the exercise trainer may begin the exercise program development process. The first step in this process a comprehensive fitness assessment. The purpose of the fitness assessment is to determine the patient's current level of fitness. This will assist in goal setting and exercise program development. It is important to note, however, that cancer-specific norm charts have yet to be developed. Thus, any score received on the fitness assessment will be compared to a norm chart representative of a healthy population. Therefore, it would be wise to set goals that are relatively modest, particularly when working with a patient who is currently in treatment.

At Maple Tree Cancer Alliance, we recommend conducting one test for each component of fitness. To measure VO2, we utilize the Bruce Treadmill Protocol, and have each patient exercise to 75% of their estimated HRmax, or volitional fatigue. To measure body composition, we conduct the 7-site skinfold assessment. Muscular endurance is measured via the partial curl-up test. Muscular Strength is assessed via hand-grip dynamometer, and finally, flexibility is measured with the modified sit-and-reach. For patients who undergo breast cancer surgery, we also measure upperbody (flexion/extension) using the goniometer, and do upper extremity circumference measurements to check for lymphedema.
