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NIHR Signal Meaningful increases in physical activity levels after cancer can be sustained for three months or more

Published on 9 July 2019

doi: 10.3310/signal-000788

People who have had cancer, who are able to keep mobile, can benefit from interventions aimed at increasing physical activity. Being active regularly is already known to improve health and may also reduce the risk of cancer returning and improve life expectancy.

This NIHR-funded review looked at what kinds of exercise interventions can lead to behaviour change in adult cancer survivors. Researchers specifically looked at the components that are linked to continued physical activity at least three months after the intervention stops.

Patients who received only printed materials also achieved modest increases in physical activity, suggesting low-intensity interventions may be sufficient in promoting small changes in behaviour for some motivated groups. By contrast, the results suggest that more intensive and costly interventions with support could be targeted at groups such as older people with physical limitations.

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Why was this study needed?

While advances in early diagnosis and treatment mean that more people are surviving cancer, the disease can have a long-term impact on health. Cancer survivors are more likely to suffer from other serious conditions, including heart disease.

Few people achieve the recommended levels of physical activity after cancer. To gain long-term health benefits, the activity has to be sustained over time, but we know little about which interventions are successful in promoting long-term change.

This is the first review of physical activity maintenance across cancer types. Reviewers looked at changes in intervention groups and control groups. Those who agree to take part in exercise trials are often highly motivated to make changes and may modify their behaviour irrespective of group allocation.

What did this study do?

This systematic review and meta-analysis pooled 19 studies which measured the effect of interventions for physical activity on 5,792 adult cancer survivors. Numbers of participants in each study ranged from 41 to 641. Studies were from the USA, Canada, Australia, the Netherlands, Hong Kong, Ireland and one from the UK.

Interventions included supervised group exercise sessions, telephone coaching, education and encouragement to do home-based exercise. Providers included physiotherapists, counsellors and health coaches. Control groups were mostly given printed exercise leaflets.

Participants were not representative of cancer populations more broadly. Many were relatively young, (average age 58) well-educated women most often after breast cancer. Self-reported physical activity measures were used, which may not be entirely accurate.

What did it find?

Three months after the end of the intervention:

  • Physical activity was maintained at a higher level: an average of 65 minutes per week (95% confidence interval [CI] 46 to 85) compared with an increase of 27 minutes in the control groups (95% CI 11 to 43).
  • Comparing the groups, interventions had a moderate effect on increasing physical activity (standardised mean difference 0.25, 95% CI 0.16 to 0.35).
  • Participants in studies that did not produce any notable change in behaviour tended to be older and had more physical limitations. Interventions in less successful groups were less likely to include a supervised element.

What does current guidance say on this issue?

NICE recommends exercise to improve cancer-related fatigue. Their general recommendations for inactive people are to build up to being moderately active for at least 150 minutes per week, with two sessions of resistance exercise each week to build muscle strength and to avoid inactivity.

This is in line with American guidelines, which recommend cancer survivors follow general population exercise guidelines.

What are the implications?

These findings support the conclusions of other studies in cancer populations that even minimal input, such as providing printed exercise advice, can increase physical activity levels.

As there was variability in the interventions provided and providers delivering them, there remains some uncertainty about how to deliver exercise programs.

Where resources are scarce, the more expensive one-to-one support could be offered to vulnerable groups, if it works for them. Younger, more physically fit adults may achieve meaningful improvement in physical activity with lower-level intervention.

Citation and Funding

Grimmett C, Corbett T, Brunet J et al. Systematic review and meta-analysis of maintenance of physical activity behaviour change in cancer survivors. Int J Behav Nutr Phys Act. 2019:16(37).

This project was funded by an NIHR post-doctoral fellowship.

Bibliography

Koutoukidis DA, Lopes S, Fisher A et al. Lifestyle advice to cancer survivors: a qualitative study on the perspectives of health professionals. London. BMJ Open. 2018;8:e020313. 

Macmillan Cancer Support. Interventions to promote physical activity for people living with and beyond cancer: evidence-based guidelines. London: Macmillan Cancer Support; 2012.

Mishra S, Scherer R, Geigle P et al. Exercise interventions on health‐related quality of life for cancer survivors. Cochrane Database Syst Rev. 2012;(8):CD007586.

NICE. Physical activity: brief advice for adults in primary care. London: National Institute for Health and Care Excellence; 2013.

NICE. Advanced breast cancer: diagnosis and treatment. London: National Institute for Health and Care Excellence; 2009.

NICE. Prostate cancer: diagnosis and management. London: National Institute for Health and Care Excellence; 2019.

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

Why was this study needed?

While advances in early diagnosis and treatment mean that more people are surviving cancer, the disease can have a long-term impact on health. Cancer survivors are more likely to suffer from other serious conditions, including heart disease.

Few people achieve the recommended levels of physical activity after cancer. To gain long-term health benefits, the activity has to be sustained over time, but we know little about which interventions are successful in promoting long-term change.

This is the first review of physical activity maintenance across cancer types. Reviewers looked at changes in intervention groups and control groups. Those who agree to take part in exercise trials are often highly motivated to make changes and may modify their behaviour irrespective of group allocation.

What did this study do?

This systematic review and meta-analysis pooled 19 studies which measured the effect of interventions for physical activity on 5,792 adult cancer survivors. Numbers of participants in each study ranged from 41 to 641. Studies were from the USA, Canada, Australia, the Netherlands, Hong Kong, Ireland and one from the UK.

Interventions included supervised group exercise sessions, telephone coaching, education and encouragement to do home-based exercise. Providers included physiotherapists, counsellors and health coaches. Control groups were mostly given printed exercise leaflets.

Participants were not representative of cancer populations more broadly. Many were relatively young, (average age 58) well-educated women most often after breast cancer. Self-reported physical activity measures were used, which may not be entirely accurate.

What did it find?

Three months after the end of the intervention:

  • Physical activity was maintained at a higher level: an average of 65 minutes per week (95% confidence interval [CI] 46 to 85) compared with an increase of 27 minutes in the control groups (95% CI 11 to 43).
  • Comparing the groups, interventions had a moderate effect on increasing physical activity (standardised mean difference 0.25, 95% CI 0.16 to 0.35).
  • Participants in studies that did not produce any notable change in behaviour tended to be older and had more physical limitations. Interventions in less successful groups were less likely to include a supervised element.

What does current guidance say on this issue?

NICE recommends exercise to improve cancer-related fatigue. Their general recommendations for inactive people are to build up to being moderately active for at least 150 minutes per week, with two sessions of resistance exercise each week to build muscle strength and to avoid inactivity.

This is in line with American guidelines, which recommend cancer survivors follow general population exercise guidelines.

What are the implications?

These findings support the conclusions of other studies in cancer populations that even minimal input, such as providing printed exercise advice, can increase physical activity levels.

As there was variability in the interventions provided and providers delivering them, there remains some uncertainty about how to deliver exercise programs.

Where resources are scarce, the more expensive one-to-one support could be offered to vulnerable groups, if it works for them. Younger, more physically fit adults may achieve meaningful improvement in physical activity with lower-level intervention.

Citation and Funding

Grimmett C, Corbett T, Brunet J et al. Systematic review and meta-analysis of maintenance of physical activity behaviour change in cancer survivors. Int J Behav Nutr Phys Act. 2019:16(37).

This project was funded by an NIHR post-doctoral fellowship.

Bibliography

Koutoukidis DA, Lopes S, Fisher A et al. Lifestyle advice to cancer survivors: a qualitative study on the perspectives of health professionals. London. BMJ Open. 2018;8:e020313. 

Macmillan Cancer Support. Interventions to promote physical activity for people living with and beyond cancer: evidence-based guidelines. London: Macmillan Cancer Support; 2012.

Mishra S, Scherer R, Geigle P et al. Exercise interventions on health‐related quality of life for cancer survivors. Cochrane Database Syst Rev. 2012;(8):CD007586.

NICE. Physical activity: brief advice for adults in primary care. London: National Institute for Health and Care Excellence; 2013.

NICE. Advanced breast cancer: diagnosis and treatment. London: National Institute for Health and Care Excellence; 2009.

NICE. Prostate cancer: diagnosis and management. London: National Institute for Health and Care Excellence; 2019.

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

Systematic review and meta-analysis of maintenance of physical activity behaviour change in cancer survivors

Published on 27 April 2019

C Grimmett, T Corbett, J Brunet, J Shepherd, B. Pinto, C May and C Foster

International Journal of Behavioural Nutrition and Physical Activity. , 2019

Background Physical activity can improve health and wellbeing after cancer and may reduce cancer recurrence and mortality. To achieve such long-term benefits cancer survivors must be habitually active. This review evaluates the effectiveness of interventions in supporting maintenance of physical activity behaviour change among adults diagnosed with cancer and explores which intervention components and contextual features are associated with effectiveness. Methods Relevant randomised controlled trials (RCTs) were identified by a search of Ovid Medline, Ovid Embase and PsychINFO. Trials including adults diagnosed with cancer, assessed an intervention targeting physical activity and reported physical activity behaviour at baseline and ≥ 3 months post-intervention were included. The behaviour change technique (BCT) taxonomy was used to identify intervention components and the Template for Intervention Description and Replication to capture contextual features. Random effect meta-analysis explored between and within group differences in physical activity behaviour. Standardised mean differences (SMD) describe effect size. Results Twenty seven RCTs were included, 19 were pooled in meta-analyses. Interventions were effective at changing long-term behaviour; SMD in moderate to vigorous physical activity (MVPA) between groups 0.25; 95% CI = 0.16–0.35. Within-group pre-post intervention analysis yielded a mean increase of 27.48 (95% CI = 11.48-43.49) mins/wk. of MVPA in control groups and 65.30 (95% CI = 45.59–85.01) mins/wk. of MVPA in intervention groups. Ineffective interventions tended to include older populations with existing physical limitations, had fewer contacts with participants, were less likely to include a supervised element or the BCTs of ‘action planning’, ‘graded tasks’ and ‘social support (unspecified)’. Included studies were biased towards inclusion of younger, female, well-educated and white populations who were already engaging in some physical activity. Conclusions Existing interventions are effective in achieving modest increases in physical activity at least 3 months post-intervention completion. Small improvements were also evident in control groups suggesting low-intensity interventions may be sufficient in promoting small changes in behaviour that last beyond intervention completion. However, study samples are not representative of typical cancer populations. Interventions should consider a stepped-care approach, providing more intensive support for older people with physical limitations and others less likely to engage in these interventions.

Author commentary

This research suggests that new programmes to support long-term increases in physical activity amongst people affected by cancer should include behaviour change techniques of action planning (considering context, frequency, duration and intensity of physical activity engagement), graded tasks (setting progressively challenging but attainable goals) and provide or encourage use of social support.

Programmes should also consider a stepped-care approach providing additional support for those with physical limitations and identify effective strategies to target those with the lowest baseline levels of activity who stand to gain the most from increased engagement.

Dr Chloe Grimmett, NIHR Post-Doctoral Research Fellow, School of Health Sciences, University of Southampton