Validation and Refinement of Prediction Models to Estimate Exercise Capacity in Cancer Survivors Using the Steep Ramp Test

Published:March 18, 2017DOI:


      • Peak oxygen consumption and peak power output can be estimated from the steep ramp test in cancer survivors.
      • A multivariable nomogram yields better predictions than does a univariable nomogram.
      • The validity of the estimations is likely to vary across different populations.
      • The estimations can be used cautiously to aid exercise prescription.
      • The estimations should not be used for clinical decision making for individuals.



      To further test the validity and clinical usefulness of the steep ramp test (SRT) in estimating exercise tolerance in cancer survivors by external validation and extension of previously published prediction models for peak oxygen consumption (Vo2peak) and peak power output (Wpeak).


      Cross-sectional study.




      Cancer survivors (N=283) in 2 randomized controlled exercise trials.


      Not applicable.

      Main Outcome Measures

      Prediction model accuracy was assessed by intraclass correlation coefficients (ICCs) and limits of agreement (LOA). Multiple linear regression was used for model extension. Clinical performance was judged by the percentage of accurate endurance exercise prescriptions.


      ICCs of SRT-predicted Vo2peak and Wpeak with these values as obtained by the cardiopulmonary exercise test were .61 and .73, respectively, using the previously published prediction models. 95% LOA were ±705mL/min with a bias of 190mL/min for Vo2peak and ±59W with a bias of 5W for Wpeak. Modest improvements were obtained by adding body weight and sex to the regression equation for the prediction of Vo2peak (ICC, .73; 95% LOA, ±608mL/min) and by adding age, height, and sex for the prediction of Wpeak (ICC, .81; 95% LOA, ±48W). Accuracy of endurance exercise prescription improved from 57% accurate prescriptions to 68% accurate prescriptions with the new prediction model for Wpeak.


      Predictions of Vo2peak and Wpeak based on the SRT are adequate at the group level, but insufficiently accurate in individual patients. The multivariable prediction model for Wpeak can be used cautiously (eg, supplemented with a Borg score) to aid endurance exercise prescription.


      List of abbreviations:

      CI (confidence interval), CPET (cardiopulmonary exercise test), ICC (intraclass correlation coefficient), LOA (limits of agreement), MET (metabolic equivalent), MSEC (maximal short exercise capacity), SRT (steep ramp test), Vo2peak (peak oxygen consumption), Wpeak (peak power output)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Vermaete N.
        • Wolter P.
        • Verhoef G.
        • Gosselink R.
        Physical activity and physical fitness in lymphoma patients before, during, and after chemotherapy: a prospective longitudinal study.
        Ann Hematol. 2014; 93: 411-424
        • Steins B.
        • Velthuis M.J.
        • Wittink H.
        Cardiopulmonary exercise testing in cancer rehabilitation: a systematic review.
        Sports Med. 2012; 42: 367-379
        • Ainsworth B.E.
        • Haskell W.L.
        • Herrmann S.D.
        • et al.
        2011 Compendium of Physical Activities: a second update of codes and MET values.
        Med Sci Sports Exerc. 2011; 43: 1575-1581
        • Jones L.W.
        • Courneya K.S.
        • Mackey J.R.
        • et al.
        Cardiopulmonary function and age-related decline across the breast cancer survivorship continuum.
        J Clin Oncol. 2012; 30: 2530-2537
        • Jones L.W.
        • Watson D.
        • Herndon II, J.E.
        • et al.
        Peak oxygen consumption and long-term all-cause mortality in nonsmall cell lung cancer.
        Cancer. 2010; 116: 4825-4832
        • Schmid D.
        • Leitzmann M.F.
        Cardiorespiratory fitness as predictor of cancer mortality: a systematic review and meta-analysis.
        Ann Oncol. 2015; 26: 272-278
        • Schmitz K.H.
        • Courneya K.S.
        • Matthews C.
        • et al.
        • American College of Sports Medicine
        American College of Sports Medicine roundtable on exercise guidelines for cancer survivors.
        Med Sci Sports Exerc. 2010; 42: 1409-1426
        • Winters-Stone K.M.
        • Neil S.E.
        • Campbell K.L.
        Attention to principles of exercise training: a review of exercise studies for survivors of cancers other than breast.
        Br J Sports Med. 2014; 48: 987-995
        • Campbell K.L.
        • Neil S.E.
        • Winters-Stone K.M.
        Review of exercise studies in breast cancer survivors: attention to principles of exercise training.
        Br J Sports Med. 2012; 46: 909-916
        • Jones L.W.
        • Eves N.D.
        • Haykowsky M.
        • Joy A.A.
        • Douglas P.S.
        Cardiorespiratory exercise testing in clinical oncology research: systematic review and practice recommendations.
        Lancet Oncol. 2008; 9: 757-765
        • Meyer K.
        • Samek L.
        • Schwaibold M.
        • et al.
        Interval training in patients with severe chronic heart failure: analysis and recommendations for exercise procedures.
        Med Sci Sports Exerc. 1997; 29: 306-312
        • De Backer I.C.
        • Schep G.
        • Hoogeveen A.
        • Vreugdenhil G.
        • Kester A.D.
        • van Breda E.
        Exercise testing and training in a cancer rehabilitation program: the advantage of the steep ramp test.
        Arch Phys Med Rehabil. 2007; 88: 610-616
        • Bongers B.C.
        • De Vries S.I.
        • Helders P.J.
        • Takken T.
        The steep ramp test in healthy children and adolescents: reliability and validity.
        Med Sci Sports Exerc. 2013; 45: 366-371
        • Jurca R.
        • Jackson A.S.
        • LaMonte M.J.
        • et al.
        Assessing cardiorespiratory fitness without performing exercise testing.
        Am J Prev Med. 2005; 29: 185-193
        • Persoon S.
        • Kersten M.J.
        • Chinapaw M.J.
        • et al.
        Design of the EXercise Intervention after Stem cell Transplantation (EXIST) study: a randomized controlled trial to evaluate the effectiveness and cost-effectiveness of an individualized high intensity physical exercise program on fitness and fatigue in patients with multiple myeloma or (non-) Hodgkin's lymphoma treated with high dose chemotherapy and autologous stem cell transplantation.
        BMC Cancer. 2010; 10: 671
        • Kampshoff C.S.
        • Buffart L.M.
        • Schep G.
        • van Mechelen W.
        • Brug J.
        • Chinapaw M.J.
        Design of the Resistance and Endurance exercise After ChemoTherapy (REACT) study: a randomized controlled trial to evaluate the effectiveness and cost-effectiveness of exercise interventions after chemotherapy on physical fitness and fatigue.
        BMC Cancer. 2010; 10: 658
        • Kampshoff C.S.
        • Chinapaw M.J.
        • Brug J.
        • et al.
        Randomized controlled trial of the effects of high intensity and low-to-moderate intensity exercise on physical fitness and fatigue in cancer survivors: results of the Resistance and Endurance exercise After ChemoTherapy (REACT) study.
        BMC Med. 2015; 13: 275
        • Chinapaw M.J.
        • Buffart L.M.
        • van Mechelen W.
        • et al.
        Alpe d'HuZes Cancer Rehabilitation (A-CaRe) research: four randomized controlled exercise trials and economic evaluations in cancer patients and survivors.
        Int J Behav Med. 2011; 19: 143-156
        • Steyerberg E.
        Clinical prediction models.
        Springer, New York2008
        • Bland J.M.
        • Altman D.G.
        Statistical methods for assessing agreement between two methods of clinical measurement.
        Lancet. 1986; 1: 307-310
        • Harrell F.
        Regression modeling strategies.
        Springer, Cham, Switzerland2015
        • Rozenberg R.
        • Bussmann J.B.
        • Lesaffre E.
        • Stam H.J.
        • Praet S.F.
        A steep ramp test is valid for estimating maximal power and oxygen uptake during a standard ramp test in type 2 diabetes.
        Scand J Med Sci Sports. 2015; 25: 595-602
        • Nunnally J.C.
        • Bernstein I.H.
        Psychometric theory.
        3rd ed. Tata McGraw-Hill Education, Delhi, India2010
        • Scharhag-Rosenberger F.
        • Kuehl R.
        • Klassen O.
        • et al.
        Exercise training intensity prescription in breast cancer survivors: validity of current practice and specific recommendations.
        J Cancer Surviv. 2015; 9: 612-619
        • Kirkham A.A.
        • Campbell K.L.
        • McKenzie D.C.
        Comparison of aerobic exercise intensity prescription methods in breast cancer.
        Med Sci Sports Exerc. 2013; 45: 1443-1450
        • Kuehl R.
        • Scharhag-Rosenberger F.
        • Schommer K.
        • et al.
        Exercise intensity classification in cancer patients undergoing allogeneic HCT.
        Med Sci Sports Exerc. 2015; 47: 889-895
        • van Waart H.
        • Stuiver M.M.
        • van Harten W.H.
        • et al.
        Effect of low-intensity physical activity and moderate- to high-intensity physical exercise during adjuvant chemotherapy on physical fitness, fatigue, and chemotherapy completion rates: results of the PACES randomized clinical trial.
        J Clin Oncol. 2015; 33: 1918-1927