Implementing Physical Exercise in Cancer Care
Ingrid Demmelmaier , Uppsala University, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long-term illness, Birgitta Johansson, Uppsala University, Department of Immunology, Genetics and Pathology, Experimental and Clinical Oncology.
Physical exercise in the context of cancer treatment is a question of global importance given the rising cancer incidence and growing number of cancer survivors. As well as preventing the development of cancer, physical exercise also relieves the toxicity of cancer treatment and diminishes the negative, long-term consequences of both the disease and the treatment. In addition, observational studies in several diagnostic groups suggest that exercise is associated with a lower risk of cancer recurrence and improved survival. Thus, the implementation of clinical guidelines to support and encourage physical exercise during and after cancer treatment cannot be overestimated and will be beneficial for individuals, the healthcare sector and society as a whole.
Desired outcomes of the workshop are:
The workshop aims to target implementation barriers and incentives for promotion and organization of physical exercise among cancer survivors during and after treatment both within and outside the healthcare system. Discussions will be on societal, organizational and individual levels, e.g. cultural aspects, legislation, financial incentives, subsidized costs, priorities, knowledge and skills.
Of particular interest will be the identification of implementation barriers and the devising of strategies to overcome these.
…for policy and decision makers in clinical cancer care to facilitate promotion of physical exercise among cancer survivors during and after treatment.
…to change clinical cancer care so that healthcare staff consistently promote physical exercise among survivors during and after treatment.
…to involve actors and arenas outside healthcare in organizing cancer survivors’ physical exercise during and after treatment.
…on an individual level, to inspire motivation among cancer survivors to initiate and maintain physical exercise during and after treatment.
The modern patient – a partner in care
Traditionally, healthcare has applied a paternalistic approach, regarding the patient primarily as a target for medical interventions and thus mainly focusing on diagnostics and treatment of the cancer. However, during the past two decades, the necessity of including the patient as a partner in care has been debated increasingly. Nowadays, patients are seen as having their own competence and therefore able to take an active part in treatment and rehabilitation. They are no longer simply a victim of the disease. Nevertheless, there are still major differences within and between countries regarding the development of person-centred care. Building a strong partnership between patient and professional requires a series of activities that enable a cancer survivor to implement and sustain behaviours to manage the illness, including support from actors both within and outside the healthcare sector.
Long-term consequences of treatment
Cancer treatment often causes events that affect patients’ wellbeing negatively and make it more difficult for them to work and manage daily activities. Cardiovascular disease is one of the most worrying complications of cancer therapies that may occur not only soon after treatment but also many years after treatment completion. Risks need to be assessed so that the prescribed exercise programme can be adjusted to individual needs.
Attitudes towards exercise for patients are changing
In the past, patients were commonly advised to rest and refrain from physical exercise during cancer treatment. Nowadays, many (but far from all) physicians and nurses in cancer care inform patients about the benefits of physical exercise, but the prescription of individualized exercise programmes and support to implement exercise in daily life are usually not part of clinical care. Thus, there is a widespread lack of evidence-based interventions to promote physical exercise during treatment in clinical cancer care. This is confirmed in scientific studies revealing that many people decrease their physical activity when they are diagnosed with cancer, a result recognized by professionals.
Also among children struck by cancer, a decrease in physical activity has been noted both during and after completion of treatment. This is alarming given that a majority of childhood cancer survivors develop late complications from treatment that could be prevented, at least to some extent, by a healthy lifestyle including regular physical exercise.
The scientific evidence of benefits of physical exercise during and after cancer treatment
The first randomized controlled trials (RCTs) investigating the effects of physical exercise during cancer treatment were conducted in the late 1980s and early 1990s. During the past two decades, the number of RCTs in this field has increased rapidly. The most common diagnostic groups included are women with breast cancer and men with prostate cancer but several other groups have also been investigated, including patients with a curable and an incurable disease. Trials have been conducted globally but with a prominent overemphasis on high-income countries.
Results from RCTs and systematic reviews show that physical exercise during and after cancer treatment has beneficial effects on muscle mass and strength, cardiorespiratory fitness, cancer-related fatigue, emotional status and other aspects of quality of life. Also, supervised exercise seems to be more efficient than unsupervised. However, there is still a need for additional research. Questions to be asked include the optimal duration of the exercise programme, frequency, intensity, type and time.
Few adverse events from exercise have been reported, the most frequently reported being common musculoskeletal disorders related to physical exercise, hypertension and dizziness. In addition, single serious complications including cardiac events have been reported. To conclude, physical exercise during and after cancer treatment is regarded as feasible and safe and there is strong scientific evidence suggesting it improves physical status and quality of life.
The effects of physical exercise for children undergoing cancer treatment have not been investigated to the same extent as for adults but there is preliminary evidence suggesting that an individualized physical exercise programme during treatment is feasible, safe and potentially beneficial.
Creating individual exercise guidelines for adults
Evidence-based clinical guidelines regarding exercise for adults with cancer have been developed in some countries but is not clear to what extent these have been implemented in routine cancer care. Existing guidelines suggest that people who are undergoing treatment can be prescribed exercise programmes in a similar way to healthy individuals. Thus, cancer survivors should be advised to engage in 150 minutes of weekly moderate-intensity aerobic exercise and resistance training at least 2 times per week. Those who are unable to exercise due to their health status should be as physically active as their conditions allow and inactivity should be avoided. Thus, the exercise programme needs to be adapted to the individual survivor based on their health status, treatment and disease trajectory. A medical assessment is needed to ensure the safety of exercise.
Challenges to physical exercise promotion
The consensus in international recommendations is a good starting point, but there are obvious challenges to performing and maintaining physical exercise during cancer treatment. Disease and treatment may affect physical, psychological and social aspects of health, potentially decreasing the chances of maintaining recommended levels of physical exercise. People accustomed to a sedentary lifestyle are likely to face even greater barriers.
The role of information
Health professionals have an important task to provide information and give advice to patients concerning disease, treatment and symptom management. When it comes to physical exercise, they should give a clear and consistent message to patients: given individual adaptations, it is safe and beneficial in terms of health and quality of life. As credible sources in this context, their capacity to impact patients’ health should be used strategically. Can professionals change their clinical practice and provide both general and individualized advice based on patients’ conditions and preferences as a routine? Whatever the case, information alone will not be sufficient to actually change patient behaviour.
To actually understand and possibly influence exercise habits, it is necessary to explore the person’s motivation, incentives, expectations, limitations and resources as well as contextual factors such as culture, family, physical environment and exercise history.
Motivation is closely linked to incentives and seems to be a mixture of importance, beliefs in own capability, and readiness to take action. Different cultural contexts influence attitudes to exercise – is it viewed as something beneficial or something to be avoided? The following three questions can be useful: How important is it to you to perform a specific type of exercise? How confident are you about doing it? How ready are you to do it? Rating answers on a 0-10 scale provides information about that the likelihood of a person actually performing a specific behaviour. Other important incentives refer to joy and rewards: rewarding activities boost autonomous motivation and facilitate exercise.
There are several effective behaviour change techniques in the field of exercise. Self-monitoring, which is about registering behaviour and outcomes, e.g. by using exercise diaries or pedometers, can be effective. Individual goal-setting and planning are also useful, as long as they are relevant and realistic.
How can this knowledge be used to implement physical exercise among cancer survivors? Drawing on research and clinical experiences, we know that supervised exercise is better than simply home-based activity and a group setting is better than an individual one (with reservations for individual preferences). How can health professionals learn to use powerful behaviour change techniques and prompt cancer survivors to seek social support for their exercise? Is it possible for cancer care to inform and initiate physical exercise, explore patients´ history and preferences, and then guide them towards a committed pathway to other exercise options outside the hospital? Such changes would need some changes in clinical practice, which may take considerable time and effort.
Changing clinical practice
Successful implementation of physical exercise in cancer care, namely individualized recommendations of suitable exercise options, is dependent on a number of factors. To start with, how are the suggestions perceived by health professionals? If they are clear-cut and seen as beneficial, they are more likely to be implemented. Another prerequisite is that the professionals have adequate knowledge and skills to give advice and guidance. If not, what can be done to improve the situation? The relationship between health professionals and patients is important and varies between countries and cultures. The readiness for change among cancer survivors is also important – do they have the necessary knowledge and attitude? And is exercise highly valued or not? The professional interaction context has to be considered: colleagues who are hesitant about changing clinical routines may hinder the implementation process. Moreover, are there resources in terms of information, incentives, time, and feedback? System barriers in terms of leadership, workload or feelings of tension about change have to be addressed, as well as any political and legal issues likely to hinder implementation. The local climate and the provision of a secure environment are important when it comes to outdoor exercise, and women may face specific challenges in some countries and cultures. All of these domains may need to be addressed.
Physical exercise promotes health but organizing it needs resources and funding. How can we develop cooperation between actors to facilitate the process, and how can we identify ways to exercise that are cheap and feasible in different cultural contexts? Workshop discussions during the Uppsala Health Summit will help to identify ideas for change and collaboration to move forward in a way that will ensure health benefits and quality of life among cancer survivors.
Bourke L, et al. Interventions for promoting habitual exercise in people living with and beyond cancer. Cochrane Database of Systematic Reviews. 2013.
Flottorp S ,et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation Science. 2013; 8:35.
Samdal GB, et al. Effective behavior change techniques for physical activity and healthy eating in overweight and obese adults: systematic review and meta-regression analyses. International Journal of Behavioral Nutrition and Physical Activity. 2017; 14:42.
Segal R, et al. Exercise for people with cancer: a clinical practice guideline. Curr Oncol. 2017; 24(1), 40-46.
Sweeger MG, et al. Which exercise prescriptions improve quality of life and physical function in patients with cancer during and following treatment? A systematic review and meta-analysis of randomised controlled trials. Br J Sports Med. 2017. doi:10.1136/bjsports-2017
 Here the term “cancer survivors” includes not only persons who are undergoing cancer treatment but also those who have completed it.