Original Title: État des connaissances - Impact de l’activité physique sur les effets indésirables associés au cancer et aux traitements oncologiques chez l’adulte

Authors' objectives: Advances in knowledge have highlighted overall health and fitness as factors that can improve cancer survivors’ prognosis and quality of life. In 2010, a first report from the American College of Sports Medicine (ACSM) stated that physical activity was safe and well tolerated by cancer patients. The authors indicated that physical activity improves cancer survivors’ physical fitness, physiological functions, and quality of life by decreasing cancer- or cancer treatment-related fatigue. However, the advanced age of some survivors and the treatments’ physical adverse effects can limit physical activity. Other studies have reported that low-intensity, short-duration, low-weekly-volume workouts nonetheless reduce certain adverse effects, such as fatigue. Some organizations encourage physical activity among cancer survivors, but studies show a significant decrease in physical activity among cancer survivors after diagnosis. Despite its promising potential, there is no structured program or recommendation at the provincial level providing a framework for physical activity among cancer survivors in Québec. It is in this context that the Programme québécois de cancérologie (PQC) of the Ministère de la Santé et des Services sociaux (MSSS) asked the Institut national d'excellence en santé et en services sociaux (INESSS) to produce a state-of-knowledge report on the impact of physical activity on the adverse effects of cancer and cancer treatments in adult survivors. The most relevant indications and organizational mechanisms, programs and measures that encourage physical activity as supportive care, which can alleviate some of the sequelae of cancer and cancer treatments, are also discussed.

Authors' results and conclusions: RESULTS (#1 CLINICAL EFFICACY OF PHYSICAL EXERCISE): Compared to routine care with no physical activity, conventional physical activity - aerobic exercises, strength training, flexibility exercises or a combination of these different types of physical activity - during or after treatment appears to: – Reduce fatigue; – Increase cardiorespiratory capacity; – Reduce depressive symptoms; – Improve cancer survivors’ quality of life. • Additional evidence would be needed to conclude that conventional physical activity has an impact on sleep. There is a growing interest in the literature regarding the efficacy and safety of alternative types of exercise, e.g., yoga, Tai Chi and Qi Gong. Alternative physical activity appears to be able to accommodate the different physical limitations of certain patients and the restrictions associated with the disease or treatments. (#2 FACTORS THAT INFLUENCE THE EFFICACY OF EXERCISE PROGRAMS): Physical activity during or after cancer treatment appears to confer significant benefits to patients. However, these benefits seem to be greater after treatment than during treatment, especially in mitigating the deterioration of cardiorespiratory capacity induced by the cardiotoxicity of cancer treatments. • Supervised physical activity appears to be more beneficial than unsupervised physical activity in: – Reducing fatigue; – Improving cardiorespiratory capacity; – Improving quality of life. • Some authors maintain that the duration of exercise programs is important for ensuring the participants’ adherence and maximizing benefits. It appears to be easier to adhere to short-term exercise programs, such as those less than 12 or 24 weeks, than to longer-term programs (more than 24 weeks). (#3 ADVERSE EFFECTS OF PHYSICAL ACTIVITY): Physical activity appears to be safe and have no significant adverse effects in cancer survivors. • An evaluation by an oncological health or physical activity professional appears to be recommended so that they can prescribe a physical activity program tailored to the patient's condition. (#4 RECOMMENDATIONS, DETAILS, AND PRESCRIBING PHYSICAL ACTIVITY TO CANCER SURVIVORS-GUIDELINES FROM INTERNATIONAL ORGANIZATIONS): The international organization guidelines recommend physical activity to facilitate the therapeutic management of survivors and to reduce the adverse effects of the disease or the treatments. • According to the guidelines, physical activity is generally safe and does not have any significant adverse effects in cancer survivors. However, they recommend: – An evaluation by a health professional prior to starting an exercise program, and frequent evaluations of the individual's condition in order to make any necessary adjustments to the physical activity program based on their physical abilities; – Supervision for survivors with minor symptoms that do not affect their ability to exercise, e.g., minor pain, fatigue, or dizziness. 4 • Physical activity should not be recommended in patients with more severe symptoms or with conditions that limit their ability to exercise. • Supervised exercise programs, alone or in combination with home-based exercises, appear to be preferable to unsupervised programs. (#5 PERSPECTIVE OF PHYSICIANS AND OTHER HEALTH PROFESSIONALS): According the literature reviewed and the experts consulted, family physicians and other health professionals in various countries recognize the importance of physical activity in cancer survivors’ care trajectory. • The experts are unanimous about the need to improve the training for health and physical activity professionals to ensure that cancer survivors can exercise safely. The lack of resources and support mechanisms, and a limited offer of services are important issues concerning the integration of physical activity as supportive care for cancer survivors. (#6 PERSPECTIVE OF CANCER SURVIVORS): According the reviewed literature, cancer survivors feel that exercise improves not only their physical fitness, but also their social interactions and their mental and cognitive abilities during group exercises. Structured supervised exercises enable them to push themselves and to improve their performance, and to feel safe doing so. • Safety concerns have been reported by cancer survivors. The lack of information and the difficulty they have discussing these concerns with their physician are obstacles to engaging in physical activity. • Supervised group exercises appear to permit safe physical activity since it promotes the tailoring of programs to the patients’ physical condition. (#7 SITUATION IN QUÉBEC AND ELSEWHERE IN CANADA): Some public exercise and physical activity programs are currently available in Québec. Most are funded entirely or partially by foundations. Some are community-based, while others are web-based or guide-based. The vast majority of them offer exercises supervised by professionals. • Elsewhere in Canada, a number of physical activity programs for cancer survivors have been set up in hospital or community settings. These programs are designed for patients during or after their treatment, and most are supervised by professionals with training in physical activity in cancer care settings. Access to these programs is often limited, and a prescription from a health professional is required. (#8 COST-EFFECTIVENESS OF PHYSICAL ACTIVITY): According to the identified literature, physical activity among cancer survivors in the developed countries is "cost-effective" for patients with colorectal or lung cancer. Conflicting results were found in the studies concerning breast cancer. • Based on the identified literature, higher-intensity exercise is more likely to be cost-effective than low-intensity programs. • According to U.S. data, patient adherence to physical activity programs reduces healthcare costs by decreasing the length of hospital stays, the number of readmissions and the number of emergency department visits. CONCLUSION: Physical activity provides many benefits to cancer survivors without causing any significant adverse effects. An evaluation by a qualified professional beforehand and supervision during the physical activity program are recommended to promote optimal tailoring to the patient’s needs and to ensure their adherence to the program. Various physical activity programs already exist in Québec and elsewhere in Canada. Some of them are offered in hospitals or in collaboration with private partners, and they are generally supervised by professionals. Knowledge of these programs and increased awareness of the benefits of physical activity could improve cancer survivors’ quality of life.

Authors' recommendations: RESULTS (#1 CLINICAL EFFICACY OF PHYSICAL EXERCISE): Compared to routine care with no physical activity, conventional physical activity - aerobic exercises, strength training, flexibility exercises or a combination of these different types of physical activity - during or after treatment appears to: – Reduce fatigue; – Increase cardiorespiratory capacity; – Reduce depressive symptoms; – Improve cancer survivors’ quality of life. • Additional evidence would be needed to conclude that conventional physical activity has an impact on sleep. There is a growing interest in the literature regarding the efficacy and safety of alternative types of exercise, e.g., yoga, Tai Chi and Qi Gong. Alternative physical activity appears to be able to accommodate the different physical limitations of certain patients and the restrictions associated with the disease or treatments. (#2 FACTORS THAT INFLUENCE THE EFFICACY OF EXERCISE PROGRAMS): Physical activity during or after cancer treatment appears to confer significant benefits to patients. However, these benefits seem to be greater after treatment than during treatment, especially in mitigating the deterioration of cardiorespiratory capacity induced by the cardiotoxicity of cancer treatments. • Supervised physical activity appears to be more beneficial than unsupervised physical activity in: – Reducing fatigue; – Improving cardiorespiratory capacity; – Improving quality of life. • Some authors maintain that the duration of exercise programs is important for ensuring the participants’ adherence and maximizing benefits. It appears to be easier to adhere to short-term exercise programs, such as those less than 12 or 24 weeks, than to longer-term programs (more than 24 weeks). (#3 ADVERSE EFFECTS OF PHYSICAL ACTIVITY): Physical activity appears to be safe and have no significant adverse effects in cancer survivors. • An evaluation by an oncological health or physical activity professional appears to be recommended so that they can prescribe a physical activity program tailored to the patient's condition. (#4 RECOMMENDATIONS, DETAILS, AND PRESCRIBING PHYSICAL ACTIVITY TO CANCER SURVIVORS-GUIDELINES FROM INTERNATIONAL ORGANIZATIONS): The international organization guidelines recommend physical activity to facilitate the therapeutic management of survivors and to reduce the adverse effects of the disease or the treatments. • According to the guidelines, physical activity is generally safe and does not have any significant adverse effects in cancer survivors. However, they recommend: – An evaluation by a health professional prior to starting an exercise program, and frequent evaluations of the individual's condition in order to make any necessary adjustments to the physical activity program based on their physical abilities; – Supervision for survivors with minor symptoms that do not affect their ability to exercise, e.g., minor pain, fatigue, or dizziness. 4 • Physical activity should not be recommended in patients with more severe symptoms or with conditions that limit their ability to exercise. • Supervised exercise programs, alone or in combination with home-based exercises, appear to be preferable to unsupervised programs. (#5 PERSPECTIVE OF PHYSICIANS AND OTHER HEALTH PROFESSIONALS): According the literature reviewed and the experts consulted, family physicians and other health professionals in various countries recognize the importance of physical activity in cancer survivors’ care trajectory. • The experts are unanimous about the need to improve the training for health and physical activity professionals to ensure that cancer survivors can exercise safely. The lack of resources and support mechanisms, and a limited offer of services are important issues concerning the integration of physical activity as supportive care for cancer survivors. (#6 PERSPECTIVE OF CANCER SURVIVORS): According the reviewed literature, cancer survivors feel that exercise improves not only their physical fitness, but also their social interactions and their mental and cognitive abilities during group exercises. Structured supervised exercises enable them to push themselves and to improve their performance, and to feel safe doing so. • Safety concerns have been reported by cancer survivors. The lack of information and the difficulty they have discussing these concerns with their physician are obstacles to engaging in physical activity. • Supervised group exercises appear to permit safe physical activity since it promotes the tailoring of programs to the patients’ physical condition. (#7 SITUATION IN QUÉBEC AND ELSEWHERE IN CANADA): Some public exercise and physical activity programs are currently available in Québec. Most are funded entirely or partially by foundations. Some are community-based, while others are web-based or guide-based. The vast majority of them offer exercises supervised by professionals. • Elsewhere in Canada, a number of physical activity programs for cancer survivors have been set up in hospital or community settings. These programs are designed for patients during or after their treatment, and most are supervised by professionals with training in physical activity in cancer care settings. Access to these programs is often limited, and a prescription from a health professional is required. (#8 COST-EFFECTIVENESS OF PHYSICAL ACTIVITY): According to the identified literature, physical activity among cancer survivors in the developed countries is "cost-effective" for patients with colorectal or lung cancer. Conflicting results were found in the studies concerning breast cancer. • Based on the identified literature, higher-intensity exercise is more likely to be cost-effective than low-intensity programs. • According to U.S. data, patient adherence to physical activity programs reduces healthcare costs by decreasing the length of hospital stays, the number of readmissions and the number of emergency department visits. CONCLUSION: Physical activity provides many benefits to cancer survivors without causing any significant adverse effects. An evaluation by a qualified professional beforehand and supervision during the physical activity program are recommended to promote optimal tailoring to the patient’s needs and to ensure their adherence to the program. Various physical activity programs already exist in Québec and elsewhere in Canada. Some of them are offered in hospitals or in collaboration with private partners, and they are generally supervised by professionals. Knowledge of these programs and increased awareness of the benefits of physical activity could improve cancer survivors’ quality of life.

Authors' methods: A systematic review of the literature data was conducted to document the efficacy and safety of physical activity in cancer survivors. The literature reviewed concerns patients − with all types and stages of cancer − during or after treatment. The scientific data, the guidelines from the main learned societies, and the experiential and contextual information gathered from the various stakeholders were integrated when drawing up the findings. The perspectives of cancer survivors and health professionals and data on the economic impact of incorporating physical activity as supportive care for cancer survivors were also documented by means of a literature review.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/impact-de-lactivite-physique-sur-les-effets-indesirables-associes-au-cancer-et-aux-traitements-oncologiques-chez-ladulte.html

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/impact-de-lactivite-physique-sur-les-effets-indesirables-associes-au-cancer-et-aux-traitements-oncologiques-chez-ladulte.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)