This exploratory study provides insight to cancer survivors’ views and experiences of receiving physical activity advice since their cancer diagnosis. Half of the cancer survivors in this study recalled receiving physical activity advice, but only one in five received advice during treatment. Of those who recalled receiving advice, only 30% received guidance on type of physical activity and just 14% were referred to another source of information or exercise specialist. Most respondents (56%) expressed the need for further information. Furthermore, we found that respondents with a higher level of education, and those who perceived the physical activity advice they received as being appropriate, were more likely to meet aerobic exercise guidelines.
The proportion of participants (52%) that recalled receiving physical activity advice is consistent with data from previous studies, reporting proportions in the range of 31–65% [6, 10,11,12]. A recent survey of 971 oncology clinicians showed that 79% of respondents felt that the treating oncologist should be the person responsible for recommending physical activity to their patients . Thus, our findings provide further evidence that, despite the importance of promoting physical activity being recognised by the oncologist workforce, patient-oncologist discussions of physical activity are not yet standard practise within cancer care.
Our findings extend those of previous studies [6, 10,11,12] by further exploring contextual factors, including the extent to which advice on specific types of physical activity was provided, and considering the important issues of timing and perceived appropriateness/sufficiency of the advice. Half of the advice given comprised of a general recommendation to be physically active (50%), with less guidance given on type of physical activity to be undertaken (30%). Walking or weight bearing exercise was the most recommended type of activity (23%). Most respondents who received advice perceived it to be appropriate (81%) and said it influenced their physical activity behaviour (62%). Nevertheless, over half of participants expressed a need for more advice (56%), particularly regarding the type and specific characteristics of physical activity (i.e. frequency, intensity, and duration) they could undertake and the associated health benefits, indicating that participants had unmet support needs. This aligns with previous qualitative research demonstrating that oncologists do not adequately address the support and information needs of colorectal and endometrial cancer survivors in relation to physical activity [13, 14].
Providing patients with specific exercise prescriptions is outside the scope of practice for oncology clinicians . Consequently, the ACSM propose that oncologists should promote the importance of physical activity to patients, triage and refer them to an appropriate exercise programme [7, 8]. However, in the present study, only 14% of participants who recalled receiving advice were referred to another source of information or exercise specialist. This is lower than the proportion of oncologists who reported referring patients to an exercise specialist (23%) or providing written information (20%) in a recent survey . Some respondents in this study expressed a need for more information on exercise resources (such as group classes and exercises specialists). The need for educational programmes to ensure that all members of the cancer care team are cognizant of the value of exercise and aware of suitable programmes that patients can be referred to has been highlighted recently .
The timing of physical activity advice could also be important to help patients control treatment side effects. Our results show that advice was mostly provided by medical professionals after the cessation of active treatment, whereas only one in five respondents (19%) received advice during treatment. Exercise is generally considered to be safe for cancer survivors during treatment and the requirement for medical clearance in those at low risk of cardiovascular events has also been removed on the basis that it is an unnecessary barrier to participation . However, medical complications associated with locoregional and systemic cancer therapies, as well as other comorbidities, may contraindicate unsupervised exercise. In this case, oncologists may refer patients to outpatient rehabilitation for further evaluation by an appropriately qualified exercise specialist, such as a clinical exercise physiologist or physical therapist. Indeed, 14% of participants in this study said their ability to be physically active was restricted by treatment-related side effects such as fatigue, musculoskeletal pain and low self-esteem, which may require an exercise specialist to prescribe a suitable exercise programme that is adapted to these side effects. This was likely an underestimation because respondents were not specifically asked this question (they raised the issue in response to an open-ended question), and previous research has identified treatment-related side effects and fatigue as key barriers to initiating or maintaining physical activity in cancer survivors . Guidance on how to identify and manage a broad range of cancer-specific exercise contraindications have been published [2, 29, 30].
We did not find evidence of an association between recall of physical activity advice and adherence to physical activity guidelines. Whilst this finding contrasts with previous research reporting a link between receiving physical activity advice and higher physical activity in colorectal cancer patients , it is well-established that providing information alone is not sufficient to change health-related behaviour . We did, however, find that cancer survivors with a higher level of education and those who perceived the physical activity advice as being appropriate were more likely to meet aerobic exercise guidelines. This finding aligns with behaviour change interventional research  and suggests that simply providing physical activity advice is not enough to influence physical activity behaviour. Research shows that cancer survivors have an interest in being physically active, but preferences and accessibility to participation opportunities vary widely . As such, it is important that healthcare professionals provide physical activity advice that is appropriate for specific sociodemographic groups and is perceived as being acceptable by the patient, which requires an individualised, patient-centred approach. This will likely require the development and dissemination of continuing education training for healthcare professionals regarding tailored delivery of physical activity advice, which is one of the major goals of ACSM’s Moving Through Cancer initiative .
Sixty percent of cancer survivors in this study were meeting aerobic exercise guidelines for cancer survivors, whereas just 24% were meeting resistance exercise guidelines . This is reflected in the type of advice given; only 5% of respondents recalled receiving a recommendation to undertake strength-promoting resistance exercise, as opposed to 32% who received advice to walk and/or undergo aerobic exercise. Interestingly, females were less likely to meet resistance exercise guidelines compared with males. This is an important finding given that 9% of advanced solid tumour patients and a quarter cancer patients with obesity are sarcopenic, and convincing evidence that low skeletal muscle mass and sarcopenia adversely impacts cancer survival outcomes . Additionally, because there is strong evidence that resistance exercise alone improves health-related outcomes in cancer survivors , further efforts are required to promote adherence to resistance exercise guidelines. Such efforts may have to be adapted to reduce inequality in participation rates between males and females.
This study has some limitations. All information collected in the survey was dependent on patient recall, which is prone to response bias. Self-reported methods of assessing physical activity may also have low validity for assessing incidental or lifestyle physical activity . Twenty-six percent of respondents received their primary cancer diagnosis ≥ 5 years prior, which means that our findings may not be representative of current cancer care. In addition, our findings do not differentiate patients with localised and advanced disease (i.e. different tumour staging, patients suffering from metastatic bone disease, etc.), which could have had some bearing on the results. The possibility of reverse causation is another potential study limitation and as most respondents were Caucasian, our findings may not be generalisable to other ethnic groups. Finally, some of the ORs in this study showed a low level of precision (evidenced by the wide 95% CIs), warranting further research to improve the certainty of estimates and confirm our exploratory findings.
In conclusion, this study showed that physical activity advice is an unmet need for cancer survivors. Most patients in this study expressed their need for further information, particularly regarding the type of physical activity they could undertake and the associated health benefits. Our findings suggest there is scope to improve the provision of physical activity advice in cancer care settings by initiating such discussions in a timely manner after diagnosis, referring patients to a suitable exercise or rehabilitation specialist when indicated, and ensuring the advice is appropriate for specific sociodemographic groups and is considered acceptable by the patient. This is challenging to implement within demanding and financially restricted healthcare systems, but will likely require the dissemination of continuing education training for healthcare professionals with input from multiple stakeholders, including those who will deliver, use, and benefit from the physical activity advice.