Implementing exercise interventions in pediatric oncology: an expert consensus framework from the FORTEe project

Background: Exercise therapy is increasingly recognized as an integral component of supportive care in pediatric oncology. However, exercise programs are not yet widely implemented nor established as standard care across Europe. The aim of this consensus statement is to provide practical recommendations for the implementation of exercise as a therapy in pediatric oncology, based on consensus from multi-disciplinary experts within the FORTEe project, funded by the European Union's Horizon 2020 research and innovation programme. Methods: The FORTEe trial (NCT05289739) is a multicenter, randomized controlled trial aiming to investigate the effects of a structured exercise intervention in children and adolescents undergoing cancer treatment. Based on this collaborative experience, this expert-informed consensus statement, derived from a structured multinational trial preparation and implementation process, presents resource-adapted recommendations to support multidisciplinary teams in initiating, expanding and sustaining precision-based exercise programs in pediatric oncology. Results: The recommendations address key domains relevant to implementation, including human resources and interprofessional role distribution, staff training, medical clearance and reasons for adapting exercise, monitoring of exercise-related complications, practical delivery of exercise programs across diverse resource settings, as well as legal and regulatory requirements. Conclusion: These recommendations offer practical, context-specific guidance to support the stepwise implementation of exercise therapy in heterogeneous pediatric oncology settings. They are intended to facilitate the safe and sustainable integration of exercise as a therapy into routine childhood cancer care, regardless of local resource availability.