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NIHR Signal Supervised exercise sessions increase physical activity and fitness of cancer survivors

Published on 11 December 2018

doi: 10.3310/signal-000695

Aerobic exercise and resistance sessions that include supervision help people living with cancer to meet guideline physical activity levels. Common behaviour change techniques that were shown to increase physical activity are goal setting, graded tasks (e.g. increasing exercise duration or intensity over time), and instruction on how to perform particular exercises.

This review update looked at the most effective ways to increase and sustain physical activity for 1,372 sedentary adults living with and beyond cancer. Most trials used exercise machines in a gym.

The findings suggest exercise was generally safe in this group of but that the quality of evidence overall was low. The majority of studies looked at women with breast cancer, so findings may not be so readily applicable to other cancers with a different range of symptoms.

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Why was this study needed?

People living with and beyond cancer can experience a range of health problems, including fatigue and poor mental health. Being regularly active can bring a range of health benefits including improved quality of life and physical function, and may also reduce the risk of cancer recurrence.

It has been estimated that less than 30% of people living with cancer meet the recommended physical activity levels. Because most cancer survivors are not regularly physically active, there is a need to understand how best to promote and sustain physical activity for these people.

This update to a 2013 Cochrane review aimed to assess which interventions are best at promoting regular exercise in adults living with and beyond cancer.

What did this study do?

The systematic review included 23 randomised controlled trials involving 1,372 sedentary adults with or recovering from cancer. The trials compared an exercise intervention with usual care or a waiting list control. Fourteen studies looked at aerobic exercise, mostly using exercise machines, such as treadmills — nine combined aerobic exercise with resistance training such as weights. Participants exercised on average two to three times per week for 12 weeks, and the majority of sessions were supervised. The exercise tolerance was assessed through the 6-minute walk test or measures like oxygen levels, heart rate or breathlessness.

Most studies were in women with breast cancer while a handful were in adults with prostate, colorectal and lung cancer. Two studies were UK-based.

Though Cochrane reviews are carried out to a high standard, the individual trials were small and at high risk of bias. Many were missing details on the number of people who continued with their exercise programmes, particularly beyond six months.

What did it find?

  • Eight trials reported intervention adherence of 75% or greater to an exercise prescription that met current physical activity guidelines and these trials all included a component of supervision (the 2013 review lacked trials that met current guidelines). Six trials reported intervention adherence of 75% or greater to an exercise prescription (aerobic exercise goal) that was less than the current physical activity guideline levels.
  • The most frequent behaviour change techniques included in all of these trials were programme goal setting, setting graded tasks, and instruction on how to perform the behaviour.
  • Exercise interventions resulted in moderate improvements in aerobic exercise tolerance at eight to 12 weeks compared with usual care (standardised mean difference [SMD] 0.54, 95% confidence interval [CI] 0.37 to 0.70; 604 participants, 10 trials, of low quality).
  • At six months, aerobic exercise tolerance also improved moderately compared with usual care (SMD 0.56, 95% CI 0.39 to 0.72; 591 participants, 7 trials, of low quality).
  • A very small number of serious adverse effects were reported amongst the trials, and it was not clear if these adverse effects were caused by inclusion in the intervention group.​

What does current guidance say on this issue?

The 2011 UK Physical Activity Guidelines for adults recommend at least 150 minutes of moderate intensity activity in bouts of 10 minutes or more per week, or 75 minutes of vigorous activity per week. Adults should also undertake strength training activity on at least two days a week and minimise sedentary behaviours.

According to Cancer Research UK, in general, the same level of activity is recommended for people with cancer as for the general population as long as it takes into account the person’s overall fitness, diagnosis and other factors that could affect safety.

What are the implications?

Evidence from this review suggests supervised exercise interventions can help people living with and beyond cancer meet recommended activity levels for up to six months.

Overall, including 10 new trials in this update has added some clarity on the behaviour change techniques that are useful in encouraging physical activity in this group.

There is now a clearer case for including these techniques in healthcare professionals’ training, including physiotherapists, who advise patients on physical activity.

However, because most trials were small and the research lacked detail on adherence, there remains uncertainty on how to effectively encourage sustained changes in physical activity beyond six months.

Citation and Funding

Turner RR, Steed L, Quirk H, et al. Interventions for promoting habitual exercise in people living with and beyond cancer. Cochrane Database Syst Rev. 2018;(9):CD010192.

Cochrane UK and the Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group are supported by NIHR infrastructure funding.

Bibliography

Bourke L, Homer KE, Thaha MA et al. Interventions for promoting habitual exercise in people living with and beyond cancer. Cochrane Database Syst Rev. 2013;(9):CD010192. 

Department of Health. UK physical activity guidelines. London: Department of Health; 2011.

Mishra S, Scherer RW, Geigle PM et al. Exercise interventions on health related quality of life for cancer survivors. Cochrane Database of Systematic Rev. 2012;(8):CD007566.

Rock CL, Doyle C, Demark‐Wahnefried W et al. Nutrition and physical activity guidelines for cancer survivors. CA: A Cancer Journal for Clinicians. 2012;62(4):242-74.

Why was this study needed?

People living with and beyond cancer can experience a range of health problems, including fatigue and poor mental health. Being regularly active can bring a range of health benefits including improved quality of life and physical function, and may also reduce the risk of cancer recurrence.

It has been estimated that less than 30% of people living with cancer meet the recommended physical activity levels. Because most cancer survivors are not regularly physically active, there is a need to understand how best to promote and sustain physical activity for these people.

This update to a 2013 Cochrane review aimed to assess which interventions are best at promoting regular exercise in adults living with and beyond cancer.

What did this study do?

The systematic review included 23 randomised controlled trials involving 1,372 sedentary adults with or recovering from cancer. The trials compared an exercise intervention with usual care or a waiting list control. Fourteen studies looked at aerobic exercise, mostly using exercise machines, such as treadmills — nine combined aerobic exercise with resistance training such as weights. Participants exercised on average two to three times per week for 12 weeks, and the majority of sessions were supervised. The exercise tolerance was assessed through the 6-minute walk test or measures like oxygen levels, heart rate or breathlessness.

Most studies were in women with breast cancer while a handful were in adults with prostate, colorectal and lung cancer. Two studies were UK-based.

Though Cochrane reviews are carried out to a high standard, the individual trials were small and at high risk of bias. Many were missing details on the number of people who continued with their exercise programmes, particularly beyond six months.

What did it find?

  • Eight trials reported intervention adherence of 75% or greater to an exercise prescription that met current physical activity guidelines and these trials all included a component of supervision (the 2013 review lacked trials that met current guidelines). Six trials reported intervention adherence of 75% or greater to an exercise prescription (aerobic exercise goal) that was less than the current physical activity guideline levels.
  • The most frequent behaviour change techniques included in all of these trials were programme goal setting, setting graded tasks, and instruction on how to perform the behaviour.
  • Exercise interventions resulted in moderate improvements in aerobic exercise tolerance at eight to 12 weeks compared with usual care (standardised mean difference [SMD] 0.54, 95% confidence interval [CI] 0.37 to 0.70; 604 participants, 10 trials, of low quality).
  • At six months, aerobic exercise tolerance also improved moderately compared with usual care (SMD 0.56, 95% CI 0.39 to 0.72; 591 participants, 7 trials, of low quality).
  • A very small number of serious adverse effects were reported amongst the trials, and it was not clear if these adverse effects were caused by inclusion in the intervention group.​

What does current guidance say on this issue?

The 2011 UK Physical Activity Guidelines for adults recommend at least 150 minutes of moderate intensity activity in bouts of 10 minutes or more per week, or 75 minutes of vigorous activity per week. Adults should also undertake strength training activity on at least two days a week and minimise sedentary behaviours.

According to Cancer Research UK, in general, the same level of activity is recommended for people with cancer as for the general population as long as it takes into account the person’s overall fitness, diagnosis and other factors that could affect safety.

What are the implications?

Evidence from this review suggests supervised exercise interventions can help people living with and beyond cancer meet recommended activity levels for up to six months.

Overall, including 10 new trials in this update has added some clarity on the behaviour change techniques that are useful in encouraging physical activity in this group.

There is now a clearer case for including these techniques in healthcare professionals’ training, including physiotherapists, who advise patients on physical activity.

However, because most trials were small and the research lacked detail on adherence, there remains uncertainty on how to effectively encourage sustained changes in physical activity beyond six months.

Citation and Funding

Turner RR, Steed L, Quirk H, et al. Interventions for promoting habitual exercise in people living with and beyond cancer. Cochrane Database Syst Rev. 2018;(9):CD010192.

Cochrane UK and the Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group are supported by NIHR infrastructure funding.

Bibliography

Bourke L, Homer KE, Thaha MA et al. Interventions for promoting habitual exercise in people living with and beyond cancer. Cochrane Database Syst Rev. 2013;(9):CD010192. 

Department of Health. UK physical activity guidelines. London: Department of Health; 2011.

Mishra S, Scherer RW, Geigle PM et al. Exercise interventions on health related quality of life for cancer survivors. Cochrane Database of Systematic Rev. 2012;(8):CD007566.

Rock CL, Doyle C, Demark‐Wahnefried W et al. Nutrition and physical activity guidelines for cancer survivors. CA: A Cancer Journal for Clinicians. 2012;62(4):242-74.

Interventions for promoting habitual exercise in people living with and beyond cancer

Published on 20 September 2018

Turner, R. R.,Steed, L.,Quirk, H.,Greasley, R. U.,Saxton, J. M.,Taylor, S. J.,Rosario, D. J.,Thaha, M. A.,Bourke, L.

Cochrane Database Syst Rev Volume 9 , 2018

BACKGROUND: This is an updated version of the original Cochrane Review published in the Cochrane Liibrary 2013, Issue 9. Despite good evidence for the health benefits of regular exercise for people living with or beyond cancer, understanding how to promote sustainable exercise behaviour change in sedentary cancer survivors, particularly over the long term, is not as well understood. A large majority of people living with or recovering from cancer do not meet current exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important for understanding the most effective strategies to ensure benefit in the patient population and identify research gaps. OBJECTIVES: To assess the effects of interventions designed to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following secondary questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals and/or healthcare professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with better behavioural outcomes? What behaviour change techniques (BCTs) are most often associated with increased exercise behaviour? What adverse effects are attributed to different exercise interventions? SEARCH METHODS: We used standard methodological procedures expected by Cochrane. We updated our 2013 Cochrane systematic review by updating the searches of the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, Embase, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro up to May 2018. We also searched the grey literature, trial registries, wrote to leading experts in the field and searched reference lists of included studies and other related recent systematic reviews. SELECTION CRITERIA: We included only randomised controlled trials (RCTs) that compared an exercise intervention with usual care or 'waiting list' control in sedentary people over the age of 18 with a homogenous primary cancer diagnosis. DATA COLLECTION AND ANALYSIS: In the update, review authors independently screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that could not be safely excluded without assessment of the full text (e.g. when no abstract is available). We extracted data from all eligible papers with at least two members of the author team working independently (RT, LS and RG). We coded BCTs according to the CALO-RE taxonomy. Risk of bias was assessed using the Cochrane's tool for assessing risk of bias. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. If statistical heterogeneity was noted, a meta-analysis was performed using a random-effects model. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation (SD) of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate the standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we narratively synthesised studies. The quality of the evidence was assessed using the GRADE approach with the GRADE profiler. MAIN RESULTS: We included 23 studies in this review, involving a total of 1372 participants (an addition of 10 studies, 724 participants from the original review); 227 full texts were screened in the update and 377 full texts were screened in the original review leaving 35 publications from a total of 23 unique studies included in the review. We planned to include all cancers, but only studies involving breast, prostate, colorectal and lung cancer met the inclusion criteria. Thirteen studies incorporated a target level of exercise that could meet current recommendations for moderate-intensity aerobic exercise (i.e.150 minutes per week); or resistance exercise (i.e. strength training exercises at least two days per week).Adherence to exercise interventions, which is crucial for understanding treatment dose, is still reported inconsistently. Eight studies reported intervention adherence of 75% or greater to an exercise prescription that met current guidelines. These studies all included a component of supervision: in our analysis of BCTs we designated these studies as 'Tier 1 trials'. Six studies reported intervention adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendations: in our analysis of BCTs we designated these studies as 'Tier 2 trials.' A hierarchy of BCTs was developed for Tier 1 and Tier 2 trials, with programme goal setting, setting of graded tasks and instruction of how to perform behaviour being amongst the most frequent BCTs. Despite the uncertainty surrounding adherence in some of the included studies, interventions resulted in improvements in aerobic exercise tolerance at eight to 12 weeks (SMD 0.54, 95% CI 0.37 to 0.70; 604 participants, 10 studies; low-quality evidence) versus usual care. At six months, aerobic exercise tolerance was also improved (SMD 0.56, 95% CI 0.39 to 0.72; 591 participants; 7 studies; low-quality evidence). AUTHORS' CONCLUSIONS: Since the last version of this review, none of the new relevant studies have provided additional information to change the conclusions. We have found some improved understanding of how to encourage previously inactive cancer survivors to achieve international physical activity guidelines. Goal setting, setting of graded tasks and instruction of how to perform behaviour, feature in interventions that meet recommendations targets and report adherence of 75% or more. However, long-term follow-up data are still limited, and the majority of studies are in white women with breast cancer. There are still a considerable number of published studies with numerous and varied issues related to high risk of bias and poor reporting standards. Additionally, the meta-analyses were often graded as consisting of low- to very low-certainty evidence. A very small number of serious adverse effects were reported amongst the studies, providing reassurance exercise is safe for this population.

Recommended physical activity guidelines were considered in this review to be at least 150 minutes per week of moderate intensity aerobic exercise with at least two days per week of strength training exercises (American Cancer Society Guidelines).

Expert commentary

Cancer diagnosis has been identified as a potential teachable moment for positive lifestyle changes, yet many individuals lack confidence and need support for initiating or resuming exercise.

This review found high adherence with supervised exercise programmes, indicating the value of receiving expert guidance. In addition, the most effective behavioural techniques for promoting exercise (goal-setting, providing graded tasks, and instruction of how to perform the behaviour) are recognised as important for increasing confidence.

The results suggest therefore that provision of professionally-led exercise opportunities that include confidence-building techniques will be most successful for promoting regular exercise in this population.

Dr Clare Stevinson, Senior Lecturer in Physical Activity and Health, Loughborough University

The commentator declares being a trustee of a cancer charity and was previously an advisor for a cancer charity