1. Introduction

From 2016–2018, there were approximately 375,400 new cases of cancer in the United Kingdom every year, which is equivalent to 1000 every day [1], with 53% of these being either breast, bowel or prostate cancer [2]. As a result, an associated increase in the number of individuals undergoing invasive treatments to tackle cancer, such as surgery, chemotherapy and radiation therapy were observed [5]. Physical activity (PA) can be an effective way to help improve survival rates, as research shows that it leads to physiological improvements such as increased flexibility, haemoglobin levels and bone mineral density [6]. However, there is evidence to suggest that 20% of cancer patients who have undergone treatment are not meeting the daily PA guidelines of 30 min of moderate PA five times per week [2]. This statistic exists despite the knowledge that PA can alleviate both physical and psychological symptoms associated with cancer treatments, such as chronic fatigue and self-efficacy, and ultimately improve quality of life [7].

Routine cancer treatments are associated with several side effects, the most common being post-cancer fatigue (PCF), which affects between 70 and 100% of patients during and post treatment [8]. PCF leads to side effects such as muscular atrophy, weight loss, reduced aerobic capacity, increased social anxiety and depression, contributing to reduced quality of life and engagement with PA [8]. Typically, cancer patients would be advised by their doctors to ‘rest and reduce their physical activity’; however, if the patient experiences no pain or shortness of breath, then PA is now recommended for physical benefits and quality of life [9]. Subsequently, the American College of Sports Medicine [10] now recommends that recovering cancer patients participate in a minimum of 150 min of moderate-intensity aerobic PA per week, such as brisk walking or swimming. However, studies suggest that most cancer survivors are insufficiently active, with those meeting the PA guidelines ranging from 17% to 47%, which results in a significant increase in the risk of developing secondary cancer or chronic illness [11,12,13,14,15,16,17,18].

Despite the benefits of PA being recognised by recovering cancer patients, many cancer survivors do not adhere to clinically advised levels. The impact of this is that the symptoms of the cancer and side effects from the treatment will cause physical, psychophysical and psychological deterioration [19]. Research exploring patient perspectives via the use of questionnaires and focus groups have highlighted several barriers to PA for cancer patients, for example, the inability to set achievable goals resulting in lowered motivation compared to pre-cancer status [20], and a lack of PA facilities and readily available information [21]. Furthermore, Knowlton et al. [22] found that patients believed the burden of their illness prevented them from undertaking PA, as their body would not let them take part. These studies highlight the need for cancer patients to receive education on PA and the benefits it can provide to help them improve their quality of life. There is evidence that social support can play an important part in PA adherence [23], and it is therefore important to consider the role that health care practitioners (HCP’s) can play in supporting cancer patients to become more physically active as part of their recovery.

In the UK, a wide range of HCP’s support cancer patients throughout their recovery, including GPs, oncologists, surgeons, nurses and health-care assistants. It is vital that health-care professionals (HCPs) possess a standardised knowledge of PA and how it can benefit cancer patients, as some HCPs do not prescribe PA for cancer recovery [24], which may be due to a lack of knowledge regarding the benefits of PA [25]. Additionally, programmes such as Cancer and Rehabilitation Exercise (CARE) have had variability and inconsistencies in how people have discovered their service, with some HCPs routinely promoting the service, some through patients conducting their own research and others word of mouth; this highlights the requirement for more effective and routine promotion to the CARE programme [23]. Research has shown oncologist recommendations to be the most influential with regards to cancer patients’ motivation to undertake PA [29]; therefore, it is essential that oncologists are aware of the benefits of PA and are confident recommending PA for cancer recovery.

Research has shown that PA helps alleviate the symptoms of cancer-related fatigue by increasing VO₂ max results (improving aerobic performance) [30] and increasing flexibility, thus reducing physical pain [31]. Van Vulpen et al. [32] conducted a meta-analysis which found that supervised PA sessions elicited significantly more improvements in fatigue reduction compared to unsupervised sessions, highlighting the importance of controlled rehabilitation programmes. There is also a dearth of literature highlighting the psychological benefits of participating in these PA interventions. Segar et al. [33] found that a 10-week moderate aerobic exercise intervention for recovering breast cancer patients reduced their symptoms of depression and state/trait anxiety, whilst Courneya et al. [34] found an increase in patient self-esteem and self-confidence in a similar exercise intervention-oriented study. This, therefore, suggests that engagement in exercise interventions is important for a healthy recovery, as well as an improvement in quality of life. Further research has explored the need to encourage recovering cancer patients to continue exercising post-intervention. Queen, Bloxham and Brow [35] found that for patients to continue being physically active without the assistance of internal systems such as practitioners or physiotherapists, they must have a close, supportive external system such as close partners/spouses to keep them motivated, with self-confidence being a vital factor in cancer patients’ PA participation [36]. To summarise, and based on the reported research, it is essential to engage HCPs in the promotion and delivery of PA as identified in key government strategies [37], as this is imperative for individuals living with cancer to ensure that they receive important information which can shape, design and deliver PA to them. 

2. The Role of PA in Cancer Patients’ Recovery from the Perspective of Exercise Practitioners

The importance of social support was highlighted in terms of the empathic understanding that existed between cancer patients, which was likened to a sense of a family. The findings resonate with Mikkelsen et al. [48], who interviewed 23 lung and pancreatic cancer survivors and found social support to be a key motivating factor for participation in PA, as it provided them with social interaction, enjoyment, and a sense of shared understanding. Social benefits therefore seem to be both a determinant and consequence of PA and their inclusion, and both in the planning and evaluation of cancer rehabilitation programmes is therefore recommended. It should also be noted, however, that not every cancer patient benefitted from a social environment, with some wanting to be undisturbed while engaging in PA. It is important to understand that every cancer patient’s experience of living with cancer will be different, and this reinforces the need for the individualisation of PA, as well as the importance of an exercise practitioner’s role in ensuring that all cancer patients are appropriately accommodated for [23]. Blaney et al. [49] supported this notion, acknowledging that whilst some cancer patients may favour individual, home-based PA, many considered supervised, individualised, group-based sessions to be their preferred form of PA delivery, in order to allow for the sharing of experiences, motivational support, and shared subjective norms. The notion of subjective norms and shared social experiences has been demonstrated in several theories of motivation and behaviour change as facilitators of sustained engagement in a given behaviour; indeed, the theory of planned behaviour [50] has been posited as a viable framework for cancer rehabilitation PA interventions [51]. 

Patients’ understanding of both physical and psychological benefits of PA emerged as another influential factor with regards to their engagement in the rehabilitation programme. Patients were unaware that PA is considered an appropriate treatment as part of their cancer recovery, which suggests that information regarding its benefits requires improved communication, as previously suggested by James-Martin et al. [52]. The psychological benefits of PA were stated as largely unknown, or unappreciated by the cancer patients; when initially starting the programme, they possessed a ‘fear of failure’ and could not understand how they would be able to take part in PA without the onset of immediate fatigue [34,53]. A lack of knowledge of, and/or belief in, the benefits of PA appeared to undermine their physical engagement, and it is therefore important that HCPs communicate the benefits of PA and lend support to patient engagement. This finding supports previous research by Blaney et al. [53], who found that despite previous experience of PA and therefore its benefits, cancer patients also harboured concerns regarding their levels of fatigue and how this may hinder engagement in PA. It therefore appears common for cancer patients to understand the benefits of PA in healthy individuals, but they lack an awareness of what it can do to help alleviate post-treatment symptoms such as fatigue and weakness and therefore they also lack a belief in their ability to engage. Nonetheless, once patients do engage, they become increasingly aware of the varied and multiple benefits that PA provides, not least of which is an increase in self-esteem and a decrease in anxiety. The cyclical nature of self-efficacy is thus evidenced in cancer patients engaging in PA for cancer rehabilitation, as it can be seen to both encourage and undermine a behaviour. Self-efficacy theory acknowledges how the construct can impact behaviour through cognitive, affective, and motivational mediating processes [54], and HCPs should therefore be cognisant of how each individual cancer patient’s mindset, and therefore level of self-efficacy, may impact their individual behaviour (i.e., engagement) with regards to PA. Exercise practitioners have also suggested that cancer patients tend to set unrealistic goals, whether those be over or under ambitious. This is where skilled HCP input is vital to PA participation for physical and psychological improvements to ensure that the goals set are appropriately planned, achievable, in line with patient needs, and can help increase motivation. Exercise practitioners suggested that setting small weekly goals helps to increase cancer patients’ motivation and alters their defeatist thought processes and attitudes as they begin to realise that they can achieve their goals. Having skilled staff who can implement, and support goal setting is therefore essential [23,55]. The ultimate aim would involve exercise practitioners, HCP’s and cancer patients designing realistic goals together, with the exercise practitioners/HCP’s providing guidance on what they believe is achievable.

A further key finding was the lack of standardised knowledge on the benefits of PA within the HCP population, as well as the lack of motivation to prescribe cancer patients to local PA programmes. Jones, Courneya, Peddle and Mackey [56] found that 55.8% of oncologists viewed PA during treatment as ‘important’, while 29.5% thought their patients were ‘capable of PA’. However, the current study found that the exercise practitioners believe it should be their job to decide whether a cancer patient is capable of PA or not. HCPs were considered to possess varying levels of knowledge of the benefits of PA on cancer patients, which results in associated variability with regard to the extent referrals are made. HCPs were also considered to lack awareness of external PA cancer rehabilitation programmes that are not affiliated with hospitals. Findings from Rutherford et al. [23] support this, whereby they reported that HCPs had varying degrees of awareness of PA programmes such as CARE, which is run externally in the community through funding from a major cancer charity. Daley et al. [57] suggested that when oncologists give advice regarding PA, they do not provide any recommendations on which programmes are best to join in the local area. Furthermore, it has been suggested that cancer patients learn of such PA programmes through media sources rather than from an HCP [58], and that 15% of doctors did not possess adequate knowledge of these referral schemes, nor were they aware of their aims [59]. However, the issue may not lay with the HCPs but may be due to a lack of appropriate opportunities for the HCPs to gain knowledge of PA referral options for their cancer patients. These are real concerns, especially in light of the recent CARE initiative which highlighted that individuals living with cancer could adopt and maintain PA levels in a safe and supportive environment, enabling them to positively impact their physical (fatigue) and psychological (quality of life) function [23]. The effectiveness of certain recent PA programmes helps to further highlight a knowledge gap and support the notion of specific roles, the importance of adopting implementation and behavioural science approaches, whilst considering sport science input/buy-in to increase uptake and remove a potential burden from HCPs. This engagement/buy-in is imperative, especially as the benefits of PA are known; therefore, behavioural changes are required by cancer patients, HCPs and potentially sport scientists to support this.

3. Conclusions