Physical activity and nutrition interventions for older adults with cancer: a systematic review

Purpose The aim of this review was to summarize the current literature for the effectiveness of activity and nutritional based interventions on health-related quality of life (HRQoL) in older adults living with and beyond cancer (LWBC). Methods We conducted systematic structured searches of CINAHL, Embase, Medline, Cochrane CENTRAL databases, and bibliographic review. Two independent researchers selected against inclusion criteria: (1) lifestyle nutrition and/or activity intervention for people with any cancer diagnosis, (2) measured HRQoL, (3) all participants over 60 years of age and (4) randomized controlled trials. Results Searches identified 5179 titles; 114 articles had full text review, with 14 studies (participant n = 1660) included. Three had nutrition and activity components, one, nutrition only and ten, activity only. Duration ranged from 7 days to 1 year. Interventions varied from intensive daily prehabilitation to home-based gardening interventions. Studies investigated various HRQoL outcomes including fatigue, general and cancer-specific quality of life (QoL), distress, depression, global side-effect burden and physical functioning. Eight studies reported significant intervention improvements in one or more QoL measure. Seven studies reported using a psychosocial/theoretical framework. There is a gap in tailored nutrition advice. Conclusions Among the few studies that targeted older adults with cancer, most were activity-based programmes with half reporting improvements in QoL. Future research should focus on or include tailored nutrition components and consider appropriate behaviour change techniques to maximize potential QoL improvement. Implications for Cancer Survivors More research is needed to address the research gap regarding older adults as current recommendations are derived from younger populations. Electronic supplementary material The online version of this article (10.1007/s11764-020-00883-x) contains supplementary material, which is available to authorized users.


Background
The proportion of adults aged 65 or older in the United Kingdom (UK) was estimated to be about 18% in 2017, with projections of an increase to around 24% by 2037 [1]. Just under two-thirds of new cancer cases in the UK, on average each year are in people aged 65 and over [2][3][4][5]. Many people post-diagnosis live with multiple adverse side effects that impact both physical and mental health. Cancer treatments are also associated with higher rates of other conditions like cardiovascular disease, type 2 diabetes and subsequent primary cancers [6].
In addition, 1 in 10 people aged 65 years or older is affected by frailty [7]. Frailty is a clinical syndrome characterized by multisystem decline that leads to lower functional reserve, increased vulnerability to dependency and mortality after minor stressor events [8]. Frailty is also associated with adverse Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11764-020-00883-x) contains supplementary material, which is available to authorized users. outcomes such as increased risk of falls, disability, hospitalization and death [9]. Older adults with cancer are at higher risk of frailty than their younger counterparts. This may limit chemotherapy and other therapeutic options or result in dose reductions and low treatment completion rates.
When coupled with higher rates of sarcopenia (the progressive degeneration of skeletal muscle mass), cachexia (extreme weight loss and muscle wasting due to chronic illness) and nutritional deficiencies (e.g. malnutrition, etc.), cancer and its treatment confer a range of effects which reduce quality of life (QoL) [10]. One recent study found that nearly two-thirds of older people assessed in hospital had at least one tissue loss syndrome (i.e. sarcopenia, frailty, cachexia or malnutrition) [11]. This is concerning as sarcopenia, for example, has been independently associated with 1-year mortality rates in older adults with cancer [12]. Obesity and fat gain have also been identified as a health issue that will become more common among older adults LWBC as the proportion of the general population classified as overweight and obese continues to increase [13,14]. The American Society of Clinical Oncology (ASCO) has even urged clinicians to intervene and counsel patients, agreeing that obesity is a major concern among people LWBC [15,16].
Physical activity (PA) benefits people living with or beyond cancer by improving physical function and QoL during and after cancer treatment, and cancer-related outcomes like treatment completion, maintenance of, or faster return to, pretreatment health, fewer unnecessary healthcare visits and better survival rates [6,[17][18][19][20][21][22]. Improvements are greater in those engaging in PA sooner after a diagnosis [23]. Rehabilitation among people with chronic obstructive pulmonary disease (COPD) is also known to reduce improve function short term [24]. Emerging work indicates that exercise and immune function in the older person are related [25][26][27][28][29][30].
Poor nutritional status is associated with worse overall survival and QoL in patients receiving chemotherapy than those with better nutritional status [31,32]. A recent review suggests that nutritional interventions, including dietary counselling and a multi-modal approach of exercise and nutrition, may support well-being and patient's ability to complete treatments; however, further high-quality research is needed [33].
A tailored activity and nutrition intervention, designed to optimize physical function and nutritional status irrespective of treatment plan, started soon after diagnosis may increase the percentage of older people able to complete chemotherapy, and improve QoL and functional ability in those unfit for chemotherapy. Previous work has focused on prehabilitation (e.g. prior to surgery) [34,35], maintenance during treatment (e.g. alongside chemotherapy) [36] or rehabilitation for cancer survivors post-treatments [37,38].
Older adults are a growing proportion of the general and cancer populations; yet, they are underrepresented in clinical trials [39,40]. In fact, a systematic review found that of all RCTs assessed in a 1-year period, only 3% were specifically designed for adults age 65 or older [41]. Additionally, older adults are often excluded based on secondary cancers, comorbidities and declines in physical function and cognition [42]. The majority of guidance for lifestyle behaviour change in cancer has been derived from early stage breast and prostate cancer populations, a generally younger, fitter, group [43]. As such, recommendations may not be appropriately generalized to older groups of poorer health, for example, adults with lung cancer, the proportion of which being aged 65 or older is 78% [2][3][4][5].
The benefits of exercise in the non-cancer population have widespread acceptance and an extensive evidence base [43], but previous research relating to exercise in cancer patients is less robust and has not been tailored to the older or frail adult. Conversely, programmes developed for older adults have not included people with cancer. The Cancer and Ageing Research Group in Wisconsin observed that "simply extracting results from the larger body of geriatric exercise trials is not sufficient to inform how exercise is prescribed for geriatric oncology patients" [44]. They recommend careful work regarding patient population selection, development of the intervention and choice of outcome measurement to enable rigorous development and testing of programmes prior to rollout in clinical practice. Therefore, we aimed to summarize the current literature regarding activity and nutritional based interventions on health-related quality of life (HRQoL) in older adults with cancer delivered before, during or after active cancer treatments, or as part of best supportive care.

Study design
The conduct and reporting of this review adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) [45]. A data charting/extraction form was adapted from the Johanna Briggs Institute (JBI) Reviewers' Manual: Methodology for JBI reviews (2015) [46]. A copy of the final form can be found on our open science framework page (https://osf.io/p23jd/).

Inclusion and exclusion criteria
Studies were included if they met the following a priori eligibility criteria: (1) delivered a lifestyle intervention for nutrition and/or PA to people with any cancer diagnosis, (2) included a measure of HRQoL, (3) participants over 60 years or at least 50% over 60 years with data analyses by age group and (4) randomized controlled trials. Studies were excluded if (1) we could not determine an age range, (2) the intervention was targeting clinicians or carers rather than older adults with cancer, (3) publication language was not in English or (4) findings were conference abstracts only.

Search strategy
Studies were identified through structured searches of all publication years (final update search performed 30 May 2019) in the following electronic databases: Medline via OVID, Embase via OVID, Cochrane Central Register of Controlled Trials (CENTRAL) and Cinahl via EBSCO. The search strategy was developed in consultation with a specialist librarian at the University of Hull and finalized with the aid of an information specialist. MeSH terms in Medline (see supplemental file 1) were developed to search for all key concepts and modified for other databases. Keyword searches restricted to abstract and title were also completed. Boolean logic was used to combine the terms. The original database searches were conducted by a single author (CF) and updated by an information specialist (SG). For the updated search, search filters for RCTs including Cochrane's Highly Sensitive Search Strategy were included to retrieve randomized controlled trials.

Study selection
All identified articles were uploaded into an EndNote X8 database and duplicates removed. Preliminary screening was undertaken by one author (CF) to remove obvious exclusions (e.g. conference abstracts, etc.) after which two authors (CF and SG) independently screened all articles against eligibility criteria taking title, abstract and full-text into account. Disagreements were discussed and resolved by consensus. Any unresolved items were reviewed by a third author (FS) and their decision stood. If criteria were unclear in the manuscript, corresponding authors were emailed and asked for clarification.

Data extraction
A data extraction form was developed and piloted by the research team to extract data about study details and characteristics (e.g. country, setting, sample characteristics, etc.), intervention details (e.g. group descriptions, intervention components and duration, etc.), QoL outcomes and key findings and messages. The form was independently tested using one article by two authors (CF and SG) and revised following discussion. Data were then extracted using the form by a single reviewer (CF). A second (SG) and third (FS) reviewer randomly selected two articles each (i.e. 25%) and reviewed the data extracted. As there were no discrepancies, data extraction by a second reviewer for the remaining articles was considered unnecessary.

Risk of bias assessment
Two authors (CF and SG) used the Risk of Bias Assessment Tool version 2 available from the Cochrane handbook (2011) to independently assess quality of life outcomes from all included studies. The articles were judged for bias as either low, high or some concerns for the following: (1) selection (random sequence generation and allocation concealment), (2) performance (blinding of participants and study personnel), (3) detection (blinding of outcome assessment), (4) missing outcome data and (5) reporting (selective outcome reporting). The nature of lifestyle behaviour change studies means double-blinding is very difficult but this tool allows fair judgements despite this fact. The authors discussed any differences and reached consensus; therefore, a third party was not necessary.

Outcomes
To describe the nature of studies currently targeting older adults with cancer, we extracted detailed information related to the intervention groups including (1) type of intervention, (2) intervention delivery methods, (3) all components of intervention, (4) study duration and measurement timing and (5) comparator group information. The primary efficacy outcomes of interest for this review were measures related to QoL or HRQoL. The primary outcomes for each study were identified and noted.

Study selection
The study selection process is presented in Fig. 1. A total of 6490 records were identified; 5179 remained after de-duplication. After title and abstract screening, 114 articles were identified for full-text review. Of those, 14 studies were deemed eligible and were included in full data extraction for this review.

Nutrition intervention characteristics
One study provided participants with all supplies and guidance on growing their own vegetables at home and had role models in the form of a Master Gardener to teach and assist [50]. One other study provided portion-control tableware to assist eating habits and included tailored nutrition advice as compared to national guidelines [56]. One study had personalized comparisons to general information regarding standard nutrition guidelines [49]. One study had a series of "healthy eating" seminars and a nutrition advice pack [48].

Theoretical intervention characteristics
Three studies explicitly stated they used a theory to develop study materials including social cognitive theory [49,50,56], transtheoretical model [49] and social ecological model [50]. Other studies included information regarding habit formation [48], autonomy [48], self-efficacy [49] and action/coping planning [47,50]. Aside from those studies with groupbased session, to increase social support, one study formally included spouses or partners in the intervention [60] and one had a private Facebook group for study participants [50].   Detailed descriptions of the interventions included can be found in Table 2.

Outcomes
Study feasibility was stated as the primary outcome for seven studies [47,48,50,54,55,58,60], of which six were deemed feasible based on recruitment, retention, adherence, and compliance rates [47,48,50,54,55,60]. Though attendance and compliance rates were high, one study was deemed not feasible due to the large number of dropouts owing to the more severe illness of bladder cancer patients [58]. Change in activity or diet behaviour was a primary outcome for two studies [48,49] and five focused on physical [52,[56][57][58] or cognitive functioning [54]. Seven found significant improvements in the primary outcome [48-50, 52, 54, 56, 57] while one found no significant group difference [58], though this was a feasibility trial. Further details can be found in Table 3.

Quality of life
Participants in a home-or group-based activity programme reported poorer general and cancer-specific QoL than those in a 1:1 personal training group [47]. Participants that received a home-based personalized activity and nutrition intervention reported similar improvements in general QoL to an attention control group receiving general information at study end which was maintained at follow-up [49]. A wait-list control group showed more positive improvement in scores for pain, Alibhai 2019 [47] Participants were an exercise programme of mixed modality exercise incorporating aerobic, strength and flexibility training. All training programmes followed the FITT principle.
An education component was included and focused on common concerns facing new exercisers. This occurred during sessions or phone calls throughout the intervention period.
All participants received resistance bands for home-based sessions. HOME group also received a stability ball, exercise mat, HR monitor with instructions, and a smartphone with a 6-month paid talk and data plan for phone check-ins.
A certified exercise physiologist delivered instructions and an orientation of exercises to all participants.
CEP delivered PT and GROUP sessions. Initial session was face to face for all participants. PT group received 1:1 face to face sessions. GROUP received supervised sessions in groups of 4-6 individuals HOME had weekly phone calls.
All participants received a print-based instruction manual to supplement home-based sessions. PT and GROUP sessions were described as "in-centre" and they were encouraged to do additional home-based sessions as the intervention progressed. HOME intervention activities were all home-based. Intervention period was 6 months.
Relative intensity was maintained throughout the programme based on baseline measures ensuring similar progression between the groups.
Each session consisted of cardiovascular training for 15-30 min, strength training (working major muscle groups), and flexibility training (including 5-10 min of stretching at the end of each session). PT and GROUP had 3 in-centre sessions per week for 6 months.
Participants were asked to do 4-5 sessions in total per week.
Programmes were tailored based on baseline fitness assessments with target HR set at 60-70% of HRR.
Health coaches delivered weekly phone calls to HOME group.
Bourke 2011 [48] Activity  Only tailored in the types of plants grown as participants were able to plan their preferred garden. Overall intervention was guided by SCT and SEM.
MGs checked in fortnightly alternating between phone or email check-ins and home visits.
Desbiens 2017 [51] This study compared two methods of delivering the same activity programme. One group performed individual, home-based exercise with the assistance of videos; another group performed the same activities in a group-based setting.
Exercise programme was developed and delivered by a kinesiologist. Exercises were approved by a surgical oncologist.
Videos were produced by researchers featuring a kinesiologist performing activities at three different intensities.
Group-based had the same exercises delivered face-to-face by the same kinesiologist. This study compared individual video-assisted, home-based activity versus group-based activity.
Video-assisted group had intervention as home-based.
Unclear where group-based activities were held. Intervention was 12 weeks in length.
Participants were asked to perform programme minimum twice per week for 12 weeks.
Exercise routine was 50 min in total: 5 min warm up; 15 min cardiovascular exercise; 20 min muscle reinforcement; 10 min relaxation.
Three levels of intensity were proposed to each participant and they selected the preferred level based on their own energy levels.

No tailoring
Lai 2017 [52] Elderly participants awaiting lobectomy were provided a prehabilitation programme that focused on improving lung fitness and cardiopulmonary intolerance to subsequently reduce postoperative pulmonary complications.
Participants were "assessed and data were recorded" by a physiotherapist, but it is unclear whether they also delivered the intervention or whether it was delivered by a member of the study team.
Intervention was delivered face-to-face.
Activity training took place in the rehabilitation centre within the hospital. The intervention was 7 days in length.
Daily activity training consisted of: Exercise sessions were delivered via print materials.
Intervention was home-based delivery The intervention was 6 weeks long Participants recorded their steps daily and were encouraged to progressively increase their steps by 5% to 20% every week.
Participants were prescribed an individually tailored walking programme based on a 4-day pedometer measurement at baseline. Participants were asked to perform 10 required exercises (e.g. squat or chest press) and four optional exercises daily following an individually tailored set/repetition scheme.
They were encouraged to progressively increase intensity, sets, and/or number of repetitions over course of the programme.
Unclear how the strength training component was tailored.
Miki 2014 [54] Speed feedback therapy with bicycle ergometer connected to computer was conducted. Participants pedalled to match the arbitrary speed displayed on the computer screen.
Pedalled while visually tracking a path and modifying their speed to follow the path.
Sessions were conducted by rehabilitation therapists.
Intervention was delivered face-to-face.  Instructors were all Yoga Alliance registered and received a dvd and instructions in addition to training with the PI to ensure they were all delivering the programme as described.
They were not allowed to add or remove anything but could modify as necessary.
Face-to-face group sessions     No other differences were observed at 14 weeks.
No differences remained or were observed at 1-year follow-up.   physical role and overall mental health compared to those receiving a gardening intervention [50]. Both the homebased and group session-based participants in an exercise intervention for women diagnosed with breast cancer improved their overall and breast cancer-specific QoL [51]. No differences were observed between groups on global or lung cancer-specific QoL in those participating in a prehabilitation intervention versus usual care [52]. In a group of mixed cancer patients undergoing chemotherapy, between group differences favouring the intervention were noted among those having poorer social and emotional well-being at baseline measures compared to the wait-list control [53]. No between-group or within-group differences were found for QoL in speed feedback therapy group versus usual care [54]. Those receiving a supervised activity programme had significant between-group improvements in overall and prostate cancer-specific QoL compared to those receiving usual care [55]. While both groups in a home-based activity and nutrition intervention versus wait-list control had declines in overall QoL throughout the study period, the intervention group had significantly smaller declines than the control group [56]. Physical and mental composite scores of the SF-36 returned to preoperative levels in participants in a functional exercise intervention when compared to those in a usual care group [57]. In an exercise study among people with bladder cancer, only the role-physical domain scores improved significantly in the intervention group compared to usual care; all other scores had no differences [58]. No differences were found between exercise and control groups in men with prostate cancer, but among spouses also participating, there was a nonsignificant increase in partners' mental health scores [60].

Fatigue and other side effects
Men starting or currently on androgen deprivation therapy (ADT) reported a similar change in fatigue among three groups receiving an activity programme [47]. Participants that received a combination of supervised and home-based activity reported more improvement in fatigue than control groups after the study period which was maintained at follow-up [48]. An activity and nutrition intervention found improvement in depression scores in both the tailored versus nontailored groups [49]. In a study comparing the same programme either home or group based, there were non-significant improvements in fatigue in both groups [51]. Participants receiving a low-to moderate-intensity home-based activity programme, with poorer anxiety and mood at baseline, had significant improvements compared to the control group [53]. Men with prostate cancer participating in aerobic exercise before radiotherapy reported significantly better fatigue scores than those in usual care [55]. Those participating in a yoga intervention reported significantly lower cancer-related fatigue and global side effect burden than the wait-list control group [59].

Discussion
This review describes the current literature around the nature of PA and nutrition interventions for older adults with cancer. Our initial inclusion age criterion was "aged 70 or older"; however, we had to amend this to 60 or older as we retrieved no studies that met all criteria illustrating the relative paucity of literature relating to older adults. Most available research has targeted relatively young people living with and beyond cancer, limiting the relevance of subsequent clinical guidance to older adults [43,[69][70][71].
We found 14 RCTs relevant to our question; most were feasibility/pilot trials, but 6 were evaluation phase studies. Effects on QoL outcomes were unsurprisingly mixed given that most were not designed to test effectiveness; however, the evaluation phase trials showed positive trends in QoL related to lifestyle interventions [49, 51-53, 55, 56]. Trials were globally representative across North America, the Far East and Europe and across all healthcare settings. Most studies were in people with prostate cancer and few included people with advanced disease; even the lung cancer prehabilitation trial included people eligible for radical surgery. Three interventions included both nutrition and PA components, with the vast majority of trials investigating a PA intervention only. Overall, our main findings are that older adults should be considered as a different population, tailoring of interventions increases relevance to the patient and a holistic approach with attention to behavioural self-management strategies with at least some personal contact with a therapist or health professional seems to be necessary.
Compared with the cancer adult population as a whole, older adults have more comorbidities, are at more risk for falls and frailty and current guidelines for behaviour change may not be relevant. However, from studies of pulmonary rehabilitation in non-malignant lung disease, older adults gain as much benefit as younger patients from such interventions although completion rates are lower; those with frailty being twice as likely not to complete [24,72,73]. Therefore, tailoring interventions is important. In the behaviour change field, studies that tailor education or interventions to individual participants are more likely to result in meaningful behaviour change [74,75]. Tailored messages are more personally relevant and are more likely to be read, understood, recalled, higher rated and seen as credible than generalized messages [74,76]. In this review, studies that tailored programmes to participants' individual capacity and preference were more likely to lead to change behaviour and in QoL measures [48][49][50]57]. The more tailored a programme is, the more relevant it will be and is more likely to result in behaviour change [76]. A recent systematic review highlighted the lack of behaviour change technique (BCT) use among thoracic cancer interventions [77]. Though we found mixed results of the effectiveness of theory-based interventions in our review, lifestyle behaviour change programmes that use appropriate BCTs to guide interventions are generally more effective [78].
The subjective nature of QoL may be different for older adults versus younger groups. Values and goals may shift for those in older age and the approach taken for lifestyle behaviour change must reflect this. Research in older adults in the general population highlights the need for more focus on functional fitness and mental well-being to remain independent [44]. The goal in this population is to live as well as possible, for as long as possible. This is reflected in the older adult cancer population where the goal or desired outcome is often functional, not fitness [44]. In this review, the majority of studies found improvements in physical function measures. One study demonstrated fewer days post-surgical recovery and a shorter hospital stay in the intervention group [52], while another study, delivering yoga found reductions in cancer-related fatigue, physical and mental fatigue, and a lower side effect burden [59]. Programmes that are more holistic in nature, focusing on both physical and mental wellness, may be most appropriate, seen as more relevant, and thereby garnering greater engagement.
Interventions with positive QoL outcomes had some form of supervised instruction or training with qualified professionals. Studies that had at least one face-to-face session were more likely to have greater positive changes in QoL measures than those that were home-based only [47,53,55,57,59]. In some studies, this was only an introductory session. While supervised activity sessions tend to have higher adherence and satisfaction, they are more expensive and resource intensive. However, studies that included telephone professional support also found positive results [49,56]. The amount of supervision needed to make a lasting difference, or the appropriate "dose" for instigating behaviour change is unknown, and a recommended avenue of study [79].
Most of the study participants were breast or prostate cancer patients during or having completed treatment. While providing important perspectives, this reduces the generalizability of recommendations outside of these groups. In particular, only two studies included people with more severe disease: one with lung cancer [57] and one in bladder cancer [58]. The bladder cancer intervention was deemed not feasible, despite the positive outcomes in the intervention group, due to the low recruitment rate and number of drop-outs highlighting the difficulty in delivering programmes to sicker patients with more comorbidities [80][81][82]. Future research should focus on ways to ensure the most appropriate programmes for these populations by development work with their target populations.
The study among lung cancer patients was also the only prehabilitation study, aimed at providing a programme designed to improve functional outcomes that would therefore reduce post-surgical complications. Participants will have been assessed as fit enough for surgery, thereby not informing clinical practice for most older adults with lung cancer. Further, while potentially very beneficial, prehabilitation studies are difficult to implement given the short time-frames necessary prior to radical cancer treatments [79,83]. Future research needs to investigate how to deliver interventions in as short a time as possible to have meaningful impact on patientcentred outcomes among those eligible for surgery.
Most studies focused on PA behaviour, highlighting the lack of nutrition interventions in older adults living with and beyond cancer despite nutritional status being a predictor for poor clinical outcomes [84]. Among the included studies, only four had a nutrition component [48][49][50]56]. The majority of advice was general and focused on comparing current nutritional intake to national guidelines [48,50,56]. Only one study that used a nutrition intervention provided more detailed and tailored advice [49]. Diet patterns have been shown to influence QoL in older adult populations [85] but little research is available that tests the differential effects of tailored PA, diet or a combination of both. More research is necessary, particularly randomized controlled trials, to determine the presence and strength of this link among the older adult LWBC population.

Limitations and strengths
Strengths include a broad search method and the use of independent researchers. However, as with any review, important papers may have been missed. As with much of cancer research, most patient groups in this review were either breast or prostate cancer reducing the generalizability of the findings. Over half of the articles included were identified as feasibility studies. Though the majority of studies indicated the interventions were feasible, they were underpowered for effectiveness. Finally, few studies indicated using any theoretical base or specific BCTs. Future research should incorporate appropriate techniques to assist self-management and help encourage higher completion rates for older adults, especially those with frailty and sarcopenia, learning from research in other conditions as relevant [72].

Implications for research
This work identified key gaps in the evidence supporting rehabilitation-based programmes for older adults with cancer, and a paucity of work including nutrition interventions alongside those aiming to improve PA. Development of acceptable and relevant interventions, flexible across the cancer continuum and cancer type and stage are needed. One size is unlikely to fit all. Future research should be underpinned by behaviour change theory and include studies to explore how best to support attendance and completion by those with frailty and sarcopenia. There is likely to be overlap with research in other areas of older adults' health and rehabilitation but although there is interest in generic rehabilitation programmes, there is little evidence to date to confirm benefits in people with cancer, or in older adults [86,87].

Conclusions
This review identified very little research that focused on older adults specifically despite the growing proportion of this group. Few studies included a nutritional component. Findings useful to inform the design of activity/nutrition programmes include candidate intervention components, the need to use a holistic and tailored approach with functional goals and some personal professional contact. The tailoring must take into account the older person's personal goals and be flexible along the cancer continuum depending on current treatment plans. Learning from general older adult populations as well as rehabilitation literature in other disease groups, e.g. chronic obstructive pulmonary disease, will help advance this research.
Authors' contributions CF, FS, ML and MJ created the concept and design of the study. CF and SG created search strategies, performed searches, screened records and extracted data. CF and MJ prepared the manuscript. All authors read and approved the final manuscript.
Funding information CF, SG and FS are supported by grants from Yorkshire Cancer Research Foundation.

Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of interest.
Ethical approval This review does not contain any studies with human participants performed by any of the authors.
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