A Systematic Search and Narrative Review of The Literature.: Yanaina Chavez Ugalde

A systematic search and narrative review of the literature.
Macmillan Cancer Support

April 2016
Yanaina Chavez Ugalde
Table of Contents
Background ........................................................................................................................................ 2
Primary objective: ....................................................................................................................................... 3
Secondary objectives: ................................................................................................................................ 3
Methods ............................................................................................................................................... 3
Search strategy ............................................................................................................................................. 3
Study selection .............................................................................................................................................. 4
Types of outcomes ....................................................................................................................................... 5
Other outcomes ............................................................................................................................................ 6
Results.................................................................................................................................................. 6
Study selection .............................................................................................................................................. 6
Characteristics of studies ......................................................................................................................... 6
Participants ................................................................................................................................................................. 7
Interventions details ............................................................................................................................................... 8
Effect of walking interventions over outcomes ........................................................................................ 11
Conclusions ..................................................................................................................................... 13
Fact-sheet ......................................................................................................................................... 14
References ....................................................................................................................................... 16
Table 1. Interventions’ characteristics ................................................................................. 19
1
Background
Cancer survivors experience a wide variety of adverse outcomes related to their cancer
diagnosis, before, during and after treatment, as well as poorer health related quality of life
(HRQoL) outcomes. Regular physical activity has an important role in alleviating some of the
side effects related to cancer and its treatment (Alfano & Rowland, 2006). Shortly after
diagnosis, physical activity levels usually decline (Irwin et al., 2003). Only 23% are active at
national recommendation levels and 31% are completely inactive (Department of Health,
2012; Webb, Foster, & Poulter, 2016). Effective interventions to obtain and maintain
sufficient levels of physical activity among PABC should be pursued.
In 2015, YouGov UK conducted an online survey to gather insight from PABC about their
views regarding physical activity. 1,011 adults with a previous cancer diagnosis responded
the online survey, and 94% considered walking to be a physical activity, 5% did not and 1%
responded not to know if it was or if it was not. “For most people, the easiest and most
acceptable forms of physical activity are those that can be incorporated into everyday life.
Examples include walking or cycling instead of travelling by car...” (Department of Health,
2004) which in turn can increase overall physical activity levels to meet recommended levels
(Irwin et al., 2009).
Behaviour change theories and behaviour change techniques (BCT) can enhance physical
activity interventions’ effectiveness. BCTs that have been effective in providing support for
behaviour change and increasing physical activity levels in cancer and long-term condition
populations are: pedometers and physical activity diaries which provide self-monitoring of
behaviour (Knols, de Bruin, Shirato, Uebelhart, & Aaronson, 2010), printed materials
(Vallance, Courneya, Plotnikoff, Yasui, & Mackey, 2007), behavioural counselling and goal
setting (Davis & Batehup, 2010), indicating that using BCTs should be promoted when
designing physical activity interventions.
There is a large body of evidence that has assessed the effects of physical activity on health
outcomes in PABC (Gokal et al., 2016; Griffith et al., 2009; Mishra et al., 2012; Singh,
Newton, Galvao, Spry, & Baker, 2013; Xu et al., 2015) , but to our knowledge, no review has
evaluated walking-only interventions in cancer populations with the aim to improve health
outcomes. Therefore, the primary aim of this review is to assess the evidence base for the
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contribution of walking specific interventions aiming to improve clinical, health related
quality of life outcomes in PABC, and explore if health resource utilisation (cost-
effectiveness, cost-benefit) was assessed in the interventions under study. Secondly, the
findings from this review will provide support to embed better practices and ongoing
improvements in health walk programmes, as well as to provide evidence for the most
effective components used in the walking interventions.
Primary objective:
✓ To assess the effects of walking interventions on clinical, HRQoL (and its domains)
among PABC.
Secondary objectives:
✓ To explore if health resource utilisation (e.g. cost-effectiveness, cost-benefit analysis)
was assessed in the interventions included in the review
✓ To explore the effectiveness of walking interventions across different types of

cancer, stage of cancer and treatment
✓ To explore BCTs used in walking interventions and assess if these enhanced

improved outcomes in PABC
✓ To explore the characteristics of the walking interventions that were most associated
with effectiveness (intervention setting, format, exercise mode, intervention
duration, number of sessions, session duration, frequency, intensity, adherence to
the intervention) and identify if any of these components can be incorporated into a
“health walk setting” and test its effectiveness there
Methods
Search strategy
Articles were searched through Metalib resource gateway from the University of Bristol,
between 7th and 15th March 2016. The databases searched were: Embase (OvidSP),
Medline (OvidSP), CINAHL, PubMed, Web of Science, and PsycINFO.
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The key terms searched were:
“Walk intervention” OR “Walking intervention”
AND
“Cancer” OR “neoplasm$” OR “tumor$” OR “tumour$” OR “malignan$” OR “cancer

survivor$” OR “cancer treatment”
AND
“quality of life” OR “health status” OR “activities of daily living” OR “pain” OR “fatigue” OR

“self concept” OR “health level” OR “wellness” OR “well being” OR “functional ability” OR
“functional assessment” OR “6MWT” OR “Six minute walking test” OR “patient reported
outcomes” OR “emotional outcomes” OR “emotional wellbeing” OR “depression” OR
“anxiety” OR “mood” OR “sleep disturbance$” OR “distress” OR “psychosocial adjustment”
OR “SF-36” OR “Medical Outcome Survey” OR “health related quality of life”
Study selection
To be eligible, studies had to have the following criteria: 1) have a walking only intervention;
2) were a randomised controlled trial and/or had a control or comparison group; 3) it was an
intervention performed in cancer populations post-diagnosis, before, during or after
treatment; 3) have at least one measure of clinical or HRQoL outcomes.
Studies were excluded if they were: 1) not published in peer-reviewed journals; 2) if they
were not in English; 3) if the intervention included any other physical activity component
that was not walking only; 4) if they were performed in any other population other than
PABC; 5) if they did not have at least one clinical or HRQoL (or any of its domains) outcome;
6) if they had no comparison or control group.
No restrictions were applied regarding publication date or country of origin. All of the
abstracts that resulted from the search were reviewed by one author (YC) and the full article
was reviewed if the abstract met the aforementioned inclusion criteria.
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Types of outcomes
Every intervention has to consider various stakeholder viewpoints (provider, patient,
funding agency), the level of funding and the scope of the study in order to select which
outcomes to include and measure. There is a wide variety of outcome types in the health
and well-being field, and interventions can focus on different outcomes, but in order to
make interventions comparable between each other the following criteria was used:
✓ Clinical – these represent the professional and provider perspective and are
measurable changes in health resulting from hospital/clinical based care. It can be
measured by activity data such as hospital re-admission rates, recurrence-free
survival from cancer, mortality rates.
✓ Health related quality of life (HRQoL) – these outcomes measure the impact of
disease and treatment on the lives of patients. Examples of outcomes that fall under
the umbrella of HRQoL are sometimes subcategorised, or studied separately in the
literature (Velentgas, Dreyer, & Wu, 2013):
o Functional capacity is considered one of the most important outcomes in the

health and well-being field because it is defined as “a fundamental
requirement for many of the activities of daily living is the ability to perform
predominantly aerobic (e.g. oxygen-using) work [...] The assessment of
functional or aerobic exercise time or peak oxygen consumption provides
important diagnostic and prognostic information in a wide variety settings.”
(Fleg, Pina, & Balady, 2000). Functional capacity can be measured objectively
by determining VO2max through a respiratory gas exchange measurement, or
estimated through maximal or sub maximal testing to estimate aerobic
capacity. The 6- or 12- minute walking test (6/12-MWT) is widely used and it
provides a powerful prognostic indicator of the ability to perform everyday
activities and also provides a good general assessment of fitness levels.
o Patient reported outcomes also fall under HRQoL. These represent the
patient’s general perception on their physical, psychological and social
aspects of life. An example of a generic measure is the Medical Outcome
Survey (SF-36), which measures eight domains: physical functioning, role
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functioning (as limited by their physical health), bodily pain, general health
perceptions, vitality, social functioning, role functioning (as limited by their
mental health) and mental health. The scores generated from this type of
generic measures provide information about the patient’s perception of their
health status and the changes experienced through the intervention. Other
patient reported outcomes, which can be measured by different
tools/questionnaires, include fatigue, anxiety, emotional and social well-
being, sleeping quality, depression.
✓ Health resource utilisation or cost measures – These outcomes represent the payer
and/or user perspective. It can include measures of cost-effectiveness measures the
relative cost and effects of the intervention had over the defined outcomes (e.g.
morbidity, mortality, years of life saved) or cost-benefit which compares the
monetary cost of an intervention against the standard of care with the cost of
savings that result from the benefit of the intervention (Velentgas et al., 2013).
Other outcomes
✓ Physical activity – objective (accelerometers/pedometers) or self-reported

(questionnaires)
✓ Stage of motivational readiness for physical activity / Exercise self-efficacy
✓ Adverse events (e.g. breathlessness, dizziness, nausea)
Results
Study selection
The search strategy produced 202 articles. Based on the review of the titles and abstracts,
31 were screened for eligibility, and after reading the full articles 16 were discarded; 15
articles met the inclusion criteria and were selected for the purpose of this review.
Characteristics of studies
Table 1 shows detailed characteristics from every article included in this review.
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Participants
The sample comprised 1,003 participants across the 15 articles included, from which 81% of
the sample were female. The majority of studies (nine) included breast cancer patients
(Gokal et al., 2016; Mock et al., 1994; Mock et al., 1997; Mock et al., 2005; Mock et al.,
2001; Rogers, Hopkins-Price, Vicari, Markwell, et al., 2009; Segal et al., 2001; Wang,
Boehmke, Wu, Dickerson, & Fisher, 2011; Yang, Tsai, Huang, & Lin, 2011), followed by a
mixed sample of cancer types (3 studies that included colorectal, ovarian, stomach,
melanoma, Hodgkin lymphoma and non-Hodgkin lymphoma, brain and lung cancer),
prostate (2 studies) and acute myelogenous leukemia (1 study). Age mean was 53.61 years
(range 44-69.3 years). Studies that reported ethnicity (Griffith et al., 2009; Mock et al., 1994;
Mock et al., 1997; Mock et al., 2005; Mock et al., 2001; Rogers, Hopkins-Price, Vicari,
Markwell, et al., 2009) were mainly white Caucasian (>76% of the sample) except for one
that was 57% black participants and 33% white-Caucasian (Monga et al., 2007). Socio
economical status was only reported by one study (Courneya et al., 2003) and employment
status was either not reported (5 studies) and when reported (10 studies)the mean of
currently employed participants was 55.8% (range 27% - 82%). Only two studies reported
the existence of current comorbidities (Mock et al., 2005; Monga et al., 2007) including:
hypertension, cardiovascular disease, diabetes, chronic obstructive pulmonary disease.
Regarding previous physical activity levels, only 2 studies (Courneya et al., 2003; Griffith et
al., 2009) reported levels of moderate to vigorous physical activity (MVPA) per week before
their cancer diagnosis through self-reported measures. Courneya et al. (2003) reported
participants that had a mean of 165 minutes of MVPA per week before their cancer
diagnosis, which exceeds the UK physical activity guidelines (Department of Health, 2011).
Nonetheless, the minutes of MVPA ranged from 117 to 227 min/week, which shows that
only some of the participants were physically active at and beyond recommended levels and
some did not reach the recommended levels (150 min/week of MVPA). Griffith et al. (2009)
only included participants that performed at least 120 minutes per week of MVPA before
their cancer diagnosis, which gives this study particular characteristics regarding
participants’ fitness levels, confidence in exercise and knowledge on how to exercise. This
may have made it easier for them to engage in the intervention, but also it could shadow
the effectiveness and impact of the walking intervention, depending on the sensitivity of the
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methods used to pick up on small changes in the outcomes measured. Three other studies
(Mock et al., 2005; Rogers, Hopkins-Price, Vicari, Markwell, et al., 2009; Wang et al., 2011)
reported having sedentary participants but did not clearly define what the criteria for
“sedentary” was, however Wang et al. (2011) reported that 46% of their participants did
walking activities within their everyday lives.
Interventions details
All of the interventions included were walking-specific and were performed amongst cancer
populations. Each intervention differed regarding the setting of delivery, its format,
intensity, frequency, session duration, number of sessions and overall intervention duration.
Nonetheless, effectiveness of interventions was consistently found across studies and
comparisons between them could be made to pick up on best practices that could inform
and be incorporated into health walks.
✓ Intensity: the average intensity across interventions was 61.4% of maximum heart
rate (HRmax) with a range of HRmax from 40 to 80%. Centers for Disease Control
and Prevention classify moderate intensity physical activity to be between 50-70%
HRmax; and vigorous intensity physical activity to be between 70 to 85% HRmax.
This suggests that designing walking interventions that aim to achieve an intensity
level of moderate-to-vigorous (compared to mild-to-moderate) can have potentially
stronger effects on health benefits for PABC in a variety of cancer types.
✓ Frequency (sessions/week): the average sessions per week across studies was 4.2
days per week and ranged from 2 to 6 days per week. The Physical Activity
Guidelines for adults recommend to achieve at least 150 minutes of moderate to
vigorous physical activity throughout the week (World Health Organization, 2016). A
way to break down the 150 min per week could be performing 30 minutes of
moderate to vigorous physical activity on 5 days of the week. Nonetheless, PABC
might not have the energy levels and motivation to comply with these
recommendations. The American College of Sports Medicine highlight that “a
gradual progression of exercise time, frequency and intensity is recommended for
best adherence and least injury risk. People unable to meet these minimums can still
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benefit from some activity days.” (Garber et al., 2011). Therefore, achieving an
average of 4 days per week of walking physical activity in PABC could be
progressively achieved.
✓ Cost measures (cost-effectiveness): The interventions included in this review did not
include health resource utilisation or cost measures regarding the cost-effectiveness
of the interventions. Nonetheless, a systematic review that analysed cost-
effectiveness of physical activity interventions in primary care (Garrett et al., 2011)
showed that interventions to increase physical activity are cost-effective, especially
when direct supervision and instruction are not required. Providing instructor-led
walking sessions, even when it is cost-effective (Garrett et al., 2011), they can be
even more cost-effective when combining supervised and non-supervised walking
sessions. Guided sessions could be provided 1-2 times per week and participants
could be guided and encouraged (using behaviour change techniques) to continue
walking (as done at guided sessions) every day of the week.
✓ Session duration (minutes): the average duration per session across studies was 28
minutes with a minimum start-up duration of 10 minutes, progressing to 30, 35, 40,
and a maximum of 45 minutes per session. Adherence to session duration is a key
factor for interventions’ effectiveness (Courneya, Friedenreich, Sela, Quinney, &
Rhodes, 2002). Strong evidence suggests that at least 30 minutes per day (in minimal
bouts of 10 minutes) on 5 days of the week [or achieving 150 minutes through the
week (World Health Organization, 2016)] of moderate to vigorous physical activity
provides strong benefits for health outcomes, and that there is a dose response in
the health benefits achieved (Lee, 2007; Oja, 2001) (e.g. achieving more minutes of
physical activity can improve health outcomes even more).
✓ Intervention/programme duration (weeks): duration of programmes varied

immensely, from 3 to 26 weeks, and an average of 11.4 weeks. The strongest effects
were seen in programme duration around 12 weeks (3 months). Only one study
(Rogers, Hopkins-Price, Vicari, Markwell, et al., 2009) provided follow-up measures
12 weeks after the intervention ended. The rest of them only provided interim and
end of intervention measures, which limits generalisability of findings regarding the
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long-term effect the intervention had (e.g. post-intervention sustainability,
maintenance of physical activity behaviour).
✓ Total number of sessions: interventions averaged a total of 41.5 sessions with a

range of 15 to 130. Therefore, aligned with intervention duration (12w), having at
least 12 weeks of active intervention, with a frequency of 3 to 5 days per week (36 to
60 sessions in total) averaging a total of 41 sessions in total has the potential to be
an effective walking intervention.
✓ Programme setting [home-based (self managed) /facility-based (supervised)]:

Eleven out of the 15 interventions were in home-based (self-managed), 2 were
facility based, and two were a combination of facility and home-based. This suggests
that providing interventions that are self-managed in a home-based setting can
provide effective results on health outcomes for cancer populations. However, BCTs
should be used to improve adherence and enhance effectiveness of the intervention.
✓ Format: all of the interventions provided individualised walking sessions. Only two
interventions provided some type of group support (not physical activity) such as
discussion group sessions with clinical psychologist (Rogers, Hopkins-Price, Vicari,
Markwell, et al., 2009) and group-based psychotherapy (Courneya et al., 2003). Even
when the physical activity sessions were individualised, there is strong evidence that
walking groups have a wide-range of health benefits in adults not affected by cancer
or long-term conditions (Hanson, 2015; Kassavou, Turner, & P French, 2013; Schulz
et al., 2015), even so, goal setting should be individually tailored to enhance
effectiveness.
✓ Adherence: Each study defined adherence differently, such as completing >50% of

the intervention or achieving more than 90 min of physical activity per week.
Regardless of their definition, to make studies comparable, adherence averaged
86.5% across studies even when most of the interventions were at home-based
setting. This finding should be taken with care since adherence to the intervention
was based on self-report measures, which have an inherent bias, especially when
recording physical activity levels (Sallis & Saelens, 2000).
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✓ Exercise mode and safety: all of the interventions used walking as the physical
activity mode and only one (Wang et al., 2011) reported having 2 participants with
adverse events such as dizziness during the intervention; however the adverse
events were not attributed to the walking intervention. These findings strengthen
the evidence that walking interventions in cancer populations are effective and safe
among PABC, either before, during or after treatment.
Effect of walking interventions over outcomes
A detail of characteristics and results from each study are shown on Table 1. All of the
studies in this review showed within group (time-effect) significant improvements in at least
one of the outcomes measured (p<0.05). Nonetheless, only 8 of the 15 interventions (Gokal
et al., 2016; Mock et al., 1997; Monga et al., 2007; Rogers, Hopkins-Price, Vicari, Markwell,
et al., 2009; Segal et al., 2001; Tang, Liou, & Lin, 2010; Wang et al., 2011; Yang et al., 2011)
provided statistical significance when analysing between group differences (intervention vs
control group). Health related quality of life outcomes were the ones most consistently
improved across studies such as: functional capacity (increased walking distance), measures
from the SF-36 (physical and mental health), fatigue, sleeping quality, anxiety, emotional
and social well-being. Other outcomes such as self-reported physical activity (Gokal et al.,
2016)(p=0.001) and objectively measured physical activity (Rogers, Hopkins-Price, Vicari,
Markwell, et al., 2009) (p=0.012) were also significantly improved. Only one study (Wang et
al., 2011) analysed exercise self-efficacy, however exercise self-efficacy was significantly
higher in exercise group at baseline (p=0.04) even so, the exercise group had a constant and
much rapid growth in exercise self-efficacy compared to the control group (usual care)
during the intervention period (p<0.001).
Sub-group analysis by Mock et al. (2001) only showed significant differences (p<0.05)
between control and intervention group when they compared participants that achieved
>90 min of physical activity on 3 times per week to participants that did not meet the
aforementioned criteria. Significant differences were found in fatigue, emotional distress,
and functional ability, suggesting that cancer populations can start experiencing health
benefits from physical activity when performing this for at least 90min per week. Albeit,
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achieving 150 min/week of moderate to vigorous physical activity should still be
progressively reached in order to boost health outcomes over time.
Even among the studies that did not show between-group differences, they all showed
improvements within-group over time on fatigue, depression, walking distance, anxiety
levels, pain, fitness, flexibility, strength [i.e. (Wang et al., 2011): fitness assessed by 6MWT
were significantly improved in subjects in the exercise group. Exercise group walked
significantly farther vs usual care after the intervention. Adjusted mean differences between
the 2 groups were 20.85 m (P = .001) at week 2-3 and 32.75 m (P = .001) at week 4;
(Windsor, Nicol, & Potter, 2004): Control group had significant increases in fatigue scores
from baseline to the end of radiotherapy (P = 0.013), with no significant increases observed
in the exercise group (P = 0.203)].
Physical activity levels (self-reported questionnaires) were examined in six interventions

(Gokal et al., 2016; Mock et al., 1997; Rogers, Hopkins-Price, Vicari, Pamenter, et al., 2009;
Wang et al., 2011; Windsor et al., 2004; Yang et al., 2011) and only one (Rogers et al., 2009)
included an objective measure (accelerometer). All of this studies reported having an
increase in physical activity level compared with the control group.
All of the interventions in this review had individualised goal setting for exercise intensity
(reaching a heart rate equivalent to moderate to vigorous physical activity 40-80 HRmax)
and goal setting for exercise duration to progressively reach the prescribed walking duration
(e.g. starting with a 10 minute walk and reaching 30 to 45 minutes on every walking
session). However, only 5 studies used behaviour change techniques (Gokal et al., 2016;
Rogers, Hopkins-Price, Vicari, Markwell, et al., 2009; Segal et al., 2001; Tang et al., 2010;
Wang et al., 2011) such as monitoring tools (pedometers, heart rate monitors), goal setting,
physical activity diary, counselling and encouragement from exercise specialist, guidance
and motivation to increase self-efficacy to exercise. These 5 interventions had significant
differences between intervention and control group. These findings strengthen the evidence
base that physical activity interventions should be accompanied by BCT to ensure its
effectiveness and have stronger effects on clinical and HRQoL outcomes in people affected
by cancer.
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Conclusions
A walking intervention in people affected by cancer before, during or after
treatment/surgery can have a positive effect on health outcomes. The strongest effects
from the interventions were seen on interventions that lasted at least 12 weeks, with 1-2
guided sessions per week and that participants completed 3 to 5 sessions per week, and
that lasted at least 30 min of moderate to vigorous walking. The strongest effects from the
walking interventions were seen on HRQoL, particularly in improving functional capacity,
reducing fatigue (especially in prostate and breast cancer survivors), reducing anxiety levels
(stronger effects on breast cancer compared to other types of cancer). Furthermore,
walking can have milder, but still positive effects on depression, sleep disturbances,
emotional well-being. Caution must be taken regarding fitness since significant effects were
understudied or not consistently affected by the walking intervention. Clinical and cost
measure outcomes were not analysed in the interventions included in this review, however
physical activity interventions have been proven to be cost-effective in primary care as well
as having similar cost-utility estimates to funded pharmaceutical interventions (Garrett et
al., 2011) in different populations.
The findings from this review provide evidence that 6 to 12 weeks of “active intervention”
can help people affected by cancer adopt walking and improve health outcomes, however,
further research should be done regarding long-term effect (after the intervention ended)
over outcomes and maintenance of physical activity behaviour in cancer populations.
The population under study was mainly white-Caucasian, female, affected by breast or
prostate cancer and with an average age >50 years, therefore findings from this review can
only be generalisable among the aforementioned population. Further research should
investigate the effect of walking interventions on other types of cancer, and hard to reach
populations such as black and ethnic minorities in order to have a broader spectrum and
stronger evidence of the effects of walking on health outcomes in other type of populations.
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Fact-sheet
✓ The findings from this review show that 6 to 12 weeks of “active walking
intervention” is an effective timeframe to help people affected by cancer adopt
physical activity behaviour.
✓ Intensity levels and walking duration (to meet physical activity guidelines) should be
individually tailored and should be achieved and gradually increased as the person
builds up confidence through the intervention or programme.
✓ When designing walking interventions, or walking programmes to improve health

outcomes in people affected by cancer, behaviour change techniques such as:
individualised goal setting (intensity, duration), using physical activity monitoring
tools (pedometers, heart rate monitors), recording physical activity behaviour in
diary, supporting individuals to overcome barriers to physical activity through
counselling and encouragement, and providing guidance and motivation to increase
self-efficacy to exercise are effective ways to enable adoption of walking in people
affected by cancer
✓ Walking can be considered to be a moderate-to-vigorous intensity activity (achieving

60 to 80% of maximal heart rate). Achieving the aforementioned level of intensity
provides improved health related quality of life outcomes particularly in improving
functional capacity, reducing fatigue and anxiety levels. Walking can also have a
milder but still positive effect on depression, sleep disturbances, emotional well-
being across different cancer types.
✓ Having a significant increase in functional capacity (e.g. walking distance), is highly

valued in people affected by cancer (Granger, McDonald, Parry, Oliveira, & Denehy,
2013; Moriello, Mayo, Feldman, & Carli, 2008). Having an improvement in functional
capacity outcomes allows individuals to recover their physical ability to
reincorporate into daily common life activities (going to the shop, climbing a set of
stairs, walking through a crossing path) and regain their independence.
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✓ The interventions in this review did not assess cost-effectiveness. However, there is
evidence that physical activity interventions are cost-effective, and providing a
combination of instructor-led with non-supervised walking sessions can enhance
cost-effectiveness even more (Garrett et al., 2011). Guided sessions could be
provided 1-2 times per week and participants could be guided and encouraged
(using behaviour change techniques) to continue walking (as done at guided
sessions) every day of the week.
✓ Adherence to walking sessions in people affected by cancer is high (>50%-100%),

with an average of 86.5%. This indicates that walking can be effectively adopted in
people affected by cancer.
✓ An increase in physical activity level can be achieved through a walking intervention.

However, there is an inherent bias on self-report measures of physical activity (Sallis
& Saelens, 2000). Therefore, objective measures (e.g. accelerometers) should be
preferred over self-report questionnaires to measure accurate physical activity
behaviour.
✓ Providing 1 or 2 days of weekly walking guided sessions, during a 12 week

programme and providing participants with the motivation and skills to be active
every day of the week aiming to achieve 150 minutes of walking at a moderate to
vigorous intensity level is achievable, effective, it can have high compliance levels
(>85%) and can effectively improve health outcomes in people affected by cancer.
15
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18
Table 1. Interventions’ characteristics
Reference Population Methods/ Outcomes (measurement tool) and Results Conclusions
Study design Components of intervention
Country
Chang, 2008 N=24: I=12; C=12 Exercise intervention: Primary outcome→ NR Not enough time to
Cancer Type→AML Type → Aerobic Secondary→ QoL including: capture intervention´s
RCT Gender→ Intensity→ target HR = - Fatigue: (BFI, and subscales): effectiveness due to the
Exercise group: Female resting + 30 - 12-MWT short length of trial
Taiwan 27.3%, male 72.7% Frequency→ 5 d/w - Overall symptom distress: (Symptom Distress
Control: Female 63.6% Duration →12 min Scale Modified Form) Small sample size
Age→ mean (SD) yrs Duration exercise - Mood disturbance: (Profile of Moods State SF)
exercise group: 49.4 program→ 3 w Exercise group had
(15.3) Total # of exercise Measures and follow-up→ baseline, 1w, 2w and 3w twice as many males as
control group: 53.3 sessions→15 sessions Retention→ Exercise group: 92%; n = 11 at baseline and control group
(13.6) Format→individual all subsequent time points; control group:92% n = 11 at
Ethnicity→NR Setting→hospital baseline and at all subsequent time points Only time effect, not
Education → NR Deliverer→ Masters-trained Subgroup analysis→None between groups
SES→NR nurse research assistant Adverse events→ NR differences
Employment (accompanied
status→NR patient on walk) Results
Comorbidities→ NR Adherence→ NR Not significant results when comparing exercise vs
Past exercise control, only group-time effect (p<0.05)
history→NR Control group: Fatigue intensity – exercise group maintained, control
Visits by trained research group increased fatigue during ttm (p=0.01)
assistant to maintain same Fatigue interference – exercise group maintained, control
patient contact group increased fatigue during ttm (p=0.002)
12-MWT – exercise group increased distance, control
decreased distance (p<0.001)
Symptom distress - higher in control group: Anxiety -
(p<0.001) and depressive status - (p<0.001)
19
Cont. Table 1. Interventions’ characteristics
Reference Population Methods/ Outcomes (measurement Conclusions
Study design Components of intervention tool) and Results
Country
Courneya, 2003 N=108; I=60(from 11 classes); C=48 (from 11 Exercise intervention: Primary outcome→ NR Moderate-vigorous
classes) Home PA+psychotherapy Secondary→ QoL (FACT-G intensity exercise
Cluster RCT Cancer Type→ various (breast 40.6%; colon Type → Aerobic (walking, but could choose and subscales for physical intervention in a
(Clusters=psych 9.4%; ovarian 5.2%; stomach 4.2%, swimming or cycling) function, emotional, home-based setting
otherapy Melanoma 4.2%; HL 3.1%; NHL, 3.1%; brain Intensity→ target 65% to 75% of estimated social/family, and spiritual may improve QoL,
classes) 3.1%; lung 3.1%; other 6%; NR 8.3%) maximum HR well-being) especially in physical
Time since cancer diagnosis→ exercise - Life satisfaction and functional
Canada group: 16.79 (18.45) months; control group: Frequency→ 3-5 times/w (SWLS) outcomes in cancer
15.71 (16.70) months Duration → 10-30 min - Depression (CES-D survivors
Receiving active treatment→ I=43.5%; C= Duration exercise program→ 10 w scale)
45.2% Total # of exercise sessions→ 30-50 - Anxiety (STAI) No concise evidence
Gender→ Exercise group: Female 84.4%; sessions - Fatigue (13-item FS of for exercise alone vs
Control: Female 86.7% Format→PA individual / psychotherapy the FACT) psychotherapy
Age→ mean (SD) yrs-exercise group: 52.51 group
(10.21); control group: 50.53 (10.08) Setting→ PA home / psychotherapy classes Duration of exercise
Ethnicity→NR in facility (Cross Cancer Institute) Measures and follow-up→ was only 10 w, does
Education →completing uni: exercise Deliverer→ Not by professional baseline and 10w not provide long-term
group: 57.1%; control:60.5% Adherence→ 85% (51/60) completed 10w Retention→ I=85%: C=94% follow-up
SES→ with family income > USD40,000: intervention; 84.3% (43/51) achieved Subgroup analysis→several
Exercise group: 63.0% minimum exercise prescription of 60 min/w Adverse events→ None Contamination: 20%
Control group: 71.1% of moderate to strenuous exercise; and of participants in
Employment status→currently employed: 31.4% (16/51) achieved optimum 150 Results exercise group did not
Exercise group: 64.61% min/w of moderate to strenuous exercise. Not significant results when meet the minimum of
Control group: 47.7% comparing exercise vs control 60 min of moderate-
Comorbidities→ NR Total minutes of exercise (SD)= vigorous PA/w and
Past exercise history→ mean (SD) minutes Exercise group: 196.65 (149.56) min Only group-time effects 20% in control group
of mild, moderate, or strenuous exercise: (p<0.05) for functional well- did
Exercise group: 192.53 (227.43)min/w Control group (contamination): being, fatigue, and sum of
Control group: 137.68 (117.76) min/w 100.91(104.24) min when participants in skinfolds.
the control group participated in exercise
Control group:
Group psychotherapy only
20
Reference Population Methods/ Outcomes (measurement tool) and Conclusions
Study design Components of intervention Results
Country
Gokal, 2016 N=50; I=25; C=25 Exercise intervention: Primary outcome→ Unsupervised,
Cancer Type→breast Home-based and self-managed - Anxiety and depression (HADS) self-managed
RCT Midway through moderate intensity walking starting at - Fatigue (FACT-F) (home-based)
chemotherapy/adjuvant ttm 80% 10 min increasing to 30 min + - Self esteem (SES) intervention has
UK Gender→ female guidance booklet with pedometer + - Mood (POMS-SF) the potential to
Age→ mean (SD) yrs goal-setting + weekly diary Secondary→ improve
Exercise group: 52.08(11.7) Type →aerobic - Physical activity levels (General psychosocial well-
Control group: 52.36 (8.9) Intensity→ moderate intensity Practice PA Questionnaire) being and increase
Ethnicity→NR Frequency→ reach 5 d/w - Exertion (Borg-scale) perception of self
Education → Duration →30 min - Steps (Pedometer) reported PA levels
SES→NR Duration exercise program→12 w Measures and follow-up→ baseline and among breast
Employment status→exercise: Total # of exercise sessions→varied 12w cancer patients
sick leave 68%; control 64% Format→individualised Retention→ NR treated with
Comorbidities→ NR Setting→home/self-managed Subgroup analysis→none chemotherapy
Past exercise history→NR Deliverer→ booklet given by Adverse events→ not by intervention
Hormone therapy→NR researcher
Adherence→ 80% Results
Significant differences between groups
Control group: regarding fatigue (p=0.02), self-esteem
Usual care (p=0.03) and increased perceived levels of
PA in the exercise group (p=0.001)
No significant differences for anxiety

(p=0.35) or depression (p=0.6)
21
Design Components of intervention
Country
Griffith, N=138; I=73; C=65 Exercise intervention: Primary outcome→CRF (peak VO2, 12-MWT) During cancer ttm,
2009 Cancer Type→ various Brisk walking 20-30-min + 5 Secondary→ physical functioning subscale (SF- a walking
Exercise group: prostate, 38 (55.9%); breast, 36); role limitations owing to physical health intervention can
min cool down (cycling could subscale (SF-36); pain level (SF-36)
RCT 23 (33.8%); colorectal, 2 (2.9%); other, 5 improve CRF, self-
supplement walking) + Measures and follow-up→ Baseline and end of
(7.4%) //control group: prostate, 32 (55.2%); reported physical
biweekly telephone calls from intervention
USA breast, 18 (31.0%); colorectal, 5 (8.6%); other, function, pain
study nurse Retention→ Exercise group 68 /68 (100%)
3 (5.2%)
Cancer stage, n (%) Stage I, 12 (10%); Stage Control group 58/58 (100%) Stronger effect on
Type → aerobic Subgroup analysis→ Outcomes by cancer type
II, 89 (70%); Stage III, 25 (20%) younger ages and
Intensity→ Moderate with 50- (prostate cancer vs other types) and secondary
Time since cancer diagnosis→ NR but prostate patients
70% max HR dose-response analysis evaluating outcomes
currently receiving treatment
Frequency→ 5x/w based on amount of PA through the PA
Gender→exercise group: fem, 41(60.3%) questionnaire independently of group An important goal
Duration →25-35 min
Control group: female 36 (62.1%) assignment due to contamination of control of exercise during
Duration exercise program→
Age→ mean (SD) yrs exercise group: 59.8 group cancer treatment
duration of cancer treatment =
(10.8); control group: 60.6 (10.8) Adverse events→ NR should be to
12.83 (5.15); range (5 to
Ethnicity→ exercise group: white non- Results preserve /improve
35 weeks)
Hispanic, 57 (83.8%); black non-Hispanic, 9 Not significant results when comparing exercise fitness, physical
Total # of exercise sessions→
(13.2%); Hispanic, 1 (1.5%);other,(1.5%) vs control function, and
varied by ttm duration
Control group: white non-Hispanic, 42 Subgroup analysis showed: reduce pain
Format→individualised
(72.5%); black non-Hispanic 11 (19.0%); Role limitations due to physical health(SF-36)
Setting→home-based
American Indian, 1 (1.7%); Asian/Pacific reported in the exercise group decreased by end Brisk walking is
Deliverer→ Not by
Islander, 2 (3.4%); Hispanic, 2 (3.4%) of cancer treatment (p=0.037) tolerable among
professional Younger age had a significant association with
Education → exercise group: high school, 7 prostate cancer
Adherence→ defined as physical function (SF-36)(p=0.048)
(10.3%); college, 35 (51.5%); graduate school, patients
walking at least 60 min/w for Average increase in PAQ was associated with a
26 (38.2%)
more than 2/3 of the total decrease in reported pain at the end of cancer
Control group: high school, 8 (13.8%); college, Older patients may
Program = 67.6% with an treatment (p=0.046), adjusted for age, cancer
17 (29.3%); graduate school, 33 (56.9%) benefit from milder
average walking time of 117 diagnosis, baseline pain and physical functioning
SES→NR exercise, such as
(105)min/w Improvement in CRF measured as %change of
Employment status→exercise group: full- leisure walking,
Control group: Peak VO2 between prostate and non-prostate
time, 31 (54.4%); part-time, 5 (8.8%); combined with
Based on encouragement to cancer patients (adjusted for baseline peak VO2
control group: full-time, 29 (55.8%); part- strength training,
maintain current activity levels and Physical Activity Questionnaire values) was
time, 6 (11.5%) 17.45% (p=0.008), with better peak VO2 which may
+ biweekly telephone calls
Past exercise history→That already did maintenance in the prostate group. On average enhance fitness
Adherence → 77.6%, and
more than 120min/w prostate group experienced 8% increase while and function, and
contamination =
Hormone therapy→NR the non-prostate suffered a 9% decrease. reduce pain.
22.4%
22
Country
Mock, 1994 N=14; I=9; C=5 Exercise intervention: Primary outcome→ Not identified Patients receiving
Cancer Type→breast cancer Incremental brisk walking + 5 min Secondary→ QoL: adjuvant
RCT cool down + support group - Physical functioning (Karnofsky chemotherapy can
Time since cancer diagnosis→ professionally led (oncology nurse have
Performance Status scale)
USA NR - accepted into a program of specialist) for 90 min every 2w during improvements in
- Psychosocial adjustment
adjuvant cytotoxic chemotherapy active treatment physical and
(Psychosocial Adjustment to Illness
Type →aerobic psychological
Scale and Brief Symptom
Gender→ Female Intensity→ NR outcomes by
Inventory)
Frequency→ 4-5 x/w doing moderate
- Self concept (total score from
Age→ mean (range) yrs Duration → 10-45 min walking exercise
Tennessee Self-Concept Scale
All : 44 (34 to 61) Duration exercise program→ and by receiving
- Body image (Body Image VAS and
duration of chemotherapy (4-6mo) support from a
Physical Self Subscale of the
Ethnicity→93% Caucasian, 7% Total # of exercise sessions→ varied group-based
Tennessee Self-Concept Scale)
Other Format→ individualised programme
- Symptom intensity (Symptoms
Education → 16 mean yrs of Setting→home
Assessment Scales)
education Deliverer→ Not by professional A moderate
SES→NR Adherence→ all exercised for a walking
Employment status→78% minimum of 30 min 3x or more/w programme with
Measures and follow-up→ Baseline, mid-
employed during treatment provision from a
treatment (3mo), end of interv and
Comorbidities→ NR professionally led
postchemotherapy(6mo)
Past exercise history→NR Control group: support group are
Retention→ 100% control and exercise
Hormone therapy→NR “usual care” feasible and safe
group
for patients
Subgroup analysis→ no
receiving adjuvant
Adverse events→ No
chemotherapy
Results
Significance (p<0.05) for overall body
image satisfaction and brief symptom
inventory
23
Country
Mock, 1997 N=50; I=22; C=24 Exercise intervention: Primary outcome→ Not identified A self-paced,
Cancer Type→ breast, Stage I, II Self incremental brisk walking 20-30 Secondary→ home-based
Quasi-RCT Time since cancer min + 5 min cool down - Physical function (12-MWT) walking exercise
diagnosis→NR Type → aerobic - Exercise level (Exercise Rating program can help
USA received breast-conserving Intensity→ NR manage symptoms
Scale -frequency and length of time
surgery; undergoing radiation Frequency→ 4-5 x/w and improve
spent exercising)
therapy Duration → 25-35 min physical
- Symptom experience (Symptom
Gender→ female Duration exercise program→ 6w functioning during
Assessment Scales - pain, skin
Age→ mean (SD) yrs Total # of exercise sessions→24-30 radiation therapy
changes, nausea, vomiting, fatigue,
Exercise group: 48.09 (5.42) sessions in women affected
diarrhoea, difficulty sleeping,
Control group: 50.29 (8.47) Format→individual by breast cancer
irritability, depression, mouth
Ethnicity→Exercise: Caucasian, Setting→home
sores, anxiety, constipation, and
18 (82%), African American, 4 Deliverer→ not by professional
body image satisfaction), assessed
(18%); Control: Caucasian, 22 Adherence→ 19/22 (86%) reported
using the
(92%), African American, 1 (4%), exercising ≥ 3 times per week for at - Fatigue (PFS)
Hispanic, 1 (4%)
least 30 minutes
Education → exercise: 15.36
Measures and follow-up→ Baseline, 3w
(2.72); control group: 14.96
Control group: for symptom experience and fatigue and all
(2.46)
usual care + regular contact from outcomes at 6w post intervention
study staff to inquire about health and Retention→ NR
SES→NR
general response to treatment Subgroup analysis→None
Employment status→ exercise:
Adverse events→ NR
full-time, 9 (41%), part-time, 9
Contamination of control group:
(41%), unemployed, 4 (18%);
“several control subjects were regular Results
control: full-time, 9 (38%), part-
walkers at the Significant differences between groups on
time, 6 (25%), unemployed, 9
time of study entry” outcome measures (p < 0.001). The
(38%)
exercise group scored significantly higher
Comorbidities→ NR
than the usual care group on physical
Past exercise history→NR
functioning (p = 0.003) and symptom
Hormone therapy→NR
intensity, particularly fatigue, anxiety, and
difficulty sleeping.
24
Country
Mock, 2001 N=52; I=NR; C=NR Exercise intervention: Primary outcome→ Not identified A home-based
Cancer Type→Breast (Stage: I, Progressive individually tailored Secondary→ QoL: walking exercise
RCT 54%; II, 40%; IIIa, 6% walking programme + contact from - Fatigue (Modified PFS, including program is
clinic staff every 2w overall fatigue and 4 fatigue potentially an
USA Time since cancer Type → Aerobic dimensions: temporal, severity, effective, low-cost,
diagnosis→NR in active Intensity→ NR affective, and sensory) and safe
treatment Frequency→ 5-6 x/w - Physical function (12-MWT, intervention to
Gender→ Female Duration →10-15 min progressing to activity level rating scale, SF-36) manage fatigue
Age→mean 47.98 (28 to 75) yrs 30 min - Emotional distress (Profile of and to improve
Ethnicity→ white, 43 (86%); Duration exercise program→ until Moods State questionnaire) QOL during
African American, 6 (12%); end of therapy - Global QoL domains (SF-36 adjuvant
Hispanic, 1 (2%) Total # of exercise sessions→varied Subscales: physical, social, and role chemotherapy or
Education →14.76 (8 to 20) yrs Format→ individualised functioning - physical limitations, radiation therapy
SES→NR Setting→home role functioning-emotional for breast cancer
Employment status→ full-time, Deliverer→ not by professional limitations, bodily pain, general patients
24 (48%); part-time, 9 (18%); Adherence→ 67% maintained mental health, vitality, general
unemployed, 17 (34%) 90min/w more than 3 daily sessions health perceptions)
Comorbidities→ NR Measures and follow-up→ Baseline and
Past exercise history→NR Control group: end of intervention
Hormone therapy→NR Usual care + contact from study staff Retention→ NR
every 2w Subgroup analysis→ high-walkers versus
Contamination: 50% were actively low-walkers due to contamination and
exercising during the study period poor adherence
Adverse events→ None
Results
Significance when segmented by achieving
>90 min on 3x/w – dose response
Women who exercised at least 90 minutes
per week on 3 or more days reported
significantly (p<0.05) less fatigue and
emotional distress as well as higher
functional ability and QOL than women
who were less active during treatment
25
Country
Mock, 2005 N=119; I=60; C=59 Exercise intervention: Primary outcome→ Fatigue (PFS) Adhering to a
Cancer Type→Breast Progressive brisk walking from 15 to Secondary→ physical function (12-MWT, home-based
RCT Exercise: Stage: 0, 20%; I, 45%: II, 30 min SF-36, PA questionnaire) moderate-
35%; IIIa, 0%; control: 0, 27.2%; Type → aerobic intensity walking
USA I, 40.7%; II, 25.4%; IIIa, 6.7% Intensity→ 50% to 70% HR max Measures and follow-up→ Baseline and exercise program
Frequency→ 5-6 x/w end of intervention may effectively
Gender→ Female Duration → 45min Retention→ 100%: exercise 54/54; mitigate the high
Duration exercise program→ 6 w control 54/54 levels of fatigue
→ including obesity (BMI > 35 (radiation) or 3 - 6 mo Subgroup analysis→ high walkers (>60 prevalent during
kg/m2), cardiovascular disease, (chemotherapy) minutes per week in more than 3 sessions) cancer treatment
acute or chronic respiratory Total # of exercise sessions→ varied vs low walkers (< 60 minutes per week)
disease, cognitive dysfunction Format→Individualised
Setting→home Adverse events→ NR
Age→ mean (SD) yrs Deliverer→ Not by professional
exercise group: 51.3 (8.9) Adherence→39/54 (72%) defined as Results
control group: 51.6 (9.7) engaging in ≥60 minutes of aerobic No significant differences between groups.
Ethnicity→Causasian: Exercise Might have occurred due to contamination
activity for at least 67% of the
85%; control 79.3% during the intervention since (39% of the
duration of the trial:
Education → exercise: 15.1 (2.8); usual care group exceeded 45 min of
control 14.9 (2.7) yrs aerobic activity weekly for 67% of the
SES→NR duration of the trial and 28% of the
Control group:
Employment status→73% exercise group did not meet 45 min of
Usual care + contact from study staff
employed aerobic activity weekly for 67% of the
every 2w
Comorbidities→ NR duration of the trial)
Past exercise Only time effect within exercise group in
Contamination→ 39% - exceeding 45
history→Sedentary women reducing fatigue levels (p=0.03)
minutes of aerobic activity weekly for
Adjuvant treatment→ radiation
67% of the duration of the trial in the
therapy, 58%; chemotherapy, control group
42%
26
Country
Monga, 2007 N=30; I=unclear (11ish); Exercise intervention: Primary outcome→ Not identified An 8-week
C=unclear (10ish) Warm up 10-15 min + 30 min Secondary→ walking exercise
RCT Cancer Type→Prostate walking treadmill + 5-10 cool - CRF (modified Bruce treadmill test) program in
Time since cancer down - Flexibility (modified sit-and-reach test) patients with
USA diagnosis→NR Type →aerobic - Strength (5x time taken to stand up and sit localized prostate
Gender→ male Intensity→ unclear (maintain down) cancer undergoing
Age→ mean (SD) yrs HR) - Fatigue (PFS) radiotherapy can
Exercise group: 68 (4.2) Frequency→ 3x/w - Global QoL (FACT-Prostate, and FACT-General) improve
range 62-77 Duration → 30min - Depression (BDI) cardiorespiratory
Control group: 70.6 (5.3) Duration exercise Outcomes were measured at baseline and end of the fitness, flexibility,
range 64-80 program→ 8w intervention at 8 weeks: muscle strength,
Ethnicity→ exercise: black, Total # of exercise Exercise group: n = 11 at baseline, n = 11 at 8 weeks and overall QoL as
7 (64%); white, 3 (27%); sessions→24 sessions Control group: n = 10 at baseline n = 10 at 8 weeks well as preventing
Hispanic, 1(9%) Format→unclear Measures and follow-up→ Baseline and end of interv fatigue in prostate
Control: black, 5 (50%); Setting→facility (8w) cancer patients
white, 4 (40%); Hispanic, 1 Deliverer→ By professional Retention→ unclear, seems 100% I: 11/11 and C:10/10
(10%) staff (kinesiotherapist) and Subgroup analysis→None
Education → exercise: supervised by a physician Adverse events→ None
12.4 (3.3) yrs Results
Control: 11.6 (2.8) yrs Adherence→ NR Significant results between exercise and control:
CRF (P=0.006), strength (P=0.000), flexibility (P<0.01),
SES→NR
Control group: fatigue (P<0.001), FACT-P (P=0.006), physical well-
Employment status→NR
Usual care being (P<0.001), social well-being (P=0.002), and
Comorbidities→ exercise:
functional well-being (P=0.04).
hypertension, 5 (45%);
Contamination→ NR Post-radiotherapy assessment: within exercise group
diabetes mellitus, 3 (27%);
improvements in:
CVD, 2 (18%); COPD, 2
CRF (P<0.001), fatigue (P=0.02); FACT-prostate
(11%)
(P=0.04); physical well-being (P=0.002)
control: hypertension, 3
social well-being (P=.02); flexibility (P=0.006)
(30%); diabetes mellitus, 3
leg strength (P=0.000)
(30%); CVD, 2 (20%);
Within control group:
COPD, 1 (10%)
Increased fatigue score (P=.004), decline in social well-
being (P<.05) at post-radiotherapy assessment.
27
Design Components of intervention
Country
Rogers, N=41; I=21; C=20 Exercise intervention: Primary outcome→ QoL and physiological: The
2009 Cancer Type→ Breast - Walking intervention + 6 discussion - PA (accelerometer) intervention
Stage I, II and III group sessions with clinical - Self-reported PA (Godin Leisure-Time Exercise resulted in
RCT 8w postsurgery psychologist baseline, and w 1, 2, 4, 6, Questionnaire) sustained
Time since cancer and 8 + 3 individual counselling with - Stage of motivational readiness for PA improvements
USA diagnosis→NR exercise specialist during w8,10, and 12 - CRF fitness (submaximal treadmill test) in physical
Gender→ Female Walking: 6 supervised sessions (3x/w - Muscle strength (back/leg and handgrip activity,
Age→ mean (SD) yrs during w 1 and 2; 2x/w during w 3 and Adverse events: None reported strength,
Exercise group: 52(15) 4; and 1 x/w during weeks 5 and 6 Measures and follow-up→ Baseline, 12w, 3mo after central
Control group: 54(8) 40 home-based exercise (2 x/w intervention adiposity, and
Ethnicity→exercise: during w 3 and 4; 3 x/w during w 5 and Retention→exercise: 21/20/19 (100%/95%/90%); social well-
white, 19 (90%); other, 2 6; 5x/w during w 7 through 12) control:20/19/17 (100%/95%/85%) being with
(10%) Type →aerobic Subgroup analysis→NR / Adverse events→ None lower extremity
Control: white, 19 (95%); Intensity→ progressive increase until Results function
other, 1 (5%) reaching 150 min moderate PA(accelerometer): significant within group time benefits
Education → exercise: intensity/w interaction (P = 0.035) and between group (mean appearing 3
15(2) Frequency→ progressive increase change from baseline to 3 mo post-intervention, 100.1 months after
Control: 15(2) from 3x/w to 5x/w minute, P = 0.012) measured as weekly min of greater intervention
SES→>50,000USD Duration → NR than or equal to moderate intensity physical activity completion
exercise: (48%); control Duration exercise program→ 12w Strength: Significant group by time interactions also
(70%) Total # of exercise sessions→52 showed sustained improvements from baseline to 3mo Testing
Employment status→NR sessions postintervention (P = 0.027) and between group translation in a
Comorbidities→ NR Format→individualised and group difference (11.2 kg; P = 0.026) multisite study
Past exercise peer support Waist-to-hip ratio: within (p = 0.041) and between is warranted
history→sedentary Setting→home and facility based group difference (-0.04; P = 0.094)
women Deliverer→ exercise professional Social well-being within (P = 0.023) and between
Hormone therapy→yes, (ACSM) group difference (P = 0.039)
estrogen receptor Adherence→Overall 99% [Individual: Delayed reduction in lower extremity dysfunction 3
modulator, aromatase 100% ; individual update: 95% ; and mo post-intervention (P = 0.045), between group
inhibitor exercise: 15 group sessions 98%] difference in the mean change from postintervention
(15) mo; control 22 (18) Control group: to 3 months follow-up (P = 0.015)
mo Usual care + informative PA written No significant group by time effect for CRF, BMI, body
materials fat %, bone density, total QoL (FACT-G), fatigue,
Contamination → NR endocrine symptoms, cognitive function, or sleep
28
Country
Segal, 2001 N=123; I (home)=42; Exercise intervention: Primary outcome→ A walking
I(supervised)=41; C=41 40 home 40 supervised - Physical functioning (SF-36) intervention,
RCT Cancer Type→breast Both: progressive walking Other outcomes included: either supervised
(stage I and II) programme + monitoring exercise - Global HRQoL, (other subscales of SF-36, or at home, can
Canada Time since cancer intensity and diary + warm-up/cool- FACT-G, and FACT-B) reduce some of
diagnosis→NR down - Aerobic capacity the negative side
During adjuvant therapy Exercise (home): only instructions to - Body weight effects of breast
(radiation, hormonal, or do home exercise prescription + Secondary→ cancer treatment,
chemo) contact by phone every 2 w during the - Global QoL (SF-36, FACT-G, FACT-B) mainly regarding
26w training period to check on - CRF physical
Gender→ Female progress and identify barriers to - Body weight functioning
Age→ mean (SD) yrs exercise Measures and follow-up→ baseline, 13w, 26w compared to usual
Exercise (home): 51.0 Exercise (supervised): supervised Retention→ 100% care
(8.7) programme (prescribed pace) Subgroup analysis→chemotherapy vs other ttm
Exercise (supervised): Type →aerobic Adverse events→ None In participants not
51.4(8.7) Intensity→ 50-60% VO2max receiving
Control: 50.3 (8.7) Frequency→ home: 5x/w; Results chemotherapy,
Ethnicity→NR supervised 3x/w at facility + Physical functioning: supervised
Education → NR instructed to 2x/w at home Control group decreased by 4.1 points; whereas it exercise may
SES→NR Duration →NR increased by 5.7 points in exercise (home) self- increase aerobic
Employment Duration exercise program→ 26w directed group and by 2.2 in exercise (supervised) capacity and
status→NR Total # of exercise sessions→130 group (P =0.04) reduce body
Comorbidities→ NR sessions Exercise (home) self-directed vs control showed a weight compared
Format→individualised moderately large (and clinically important) with usual care
Past exercise Setting→home and facility difference vs control (9.8 points; P =0.01) and
history→self-reported supervised between the supervised vs control only a modest
as physically active Deliverer→ By exercise professional difference (6.3 points; P =0.09)
[exercise (home); 60%; Adherence→ NR No significant differences between groups for QoL
exercise (supervised) In a secondary analysis of participants stratified by
50%; control: 47.6%] Control group: type of adjuvant therapy, supervised exercise
Hormone therapy→NR 41 advised by oncologist to exercise at improved CRF (+3.5 mL/kg/min; P =.01) and
a level that felt right for them, reduced body weight (-4.8 kg; P <.05) vs control
informed about the benefits of PA group only in participants not receiving
chemotherapy.
29
Country
Tang, 2010 N=72; I=37; C=35 Exercise intervention: Primary outcome→ Sleep
Cancer Type→exercise: breast, 5 min warm-up, 30 min of brisk - Sleep quality (PSQI) disturbances in
RCT 23 (63.9%); gastrointestinal, 6 walking, 5 min cool down + written Secondary→ cancer patients
(16.7%); nasopharyngeal, 4 booklet material (safety and - QoL (SF-36-physical and mental can be strongly
Taiwan (11.1%); lung, 0 (0%); other, 3 technique) component status) ameliorated with
(8.3%) a walking exercise
control: breast, 16 (45.7%); Type →aerobic Measures and follow-up→ baseline, 4w, programme
gastrointestinal, 5 (14.3%); Intensity→ perceived exertion of 11 8w implemented at
nasopharyngeal, 3 and 13 (6 resting, 20 highest level of Retention→ exercise: 37/35/36 home for a period
(8.6%); lung, 4 (11.4%); other, 7 exhaustion) (100%/95%/97%) of 8w
(20%) Frequency→ 3 x/w Control: 35/35/35 (100%/100%/100%)
Duration →30 min The walking
Time since cancer diagnosis→3 Duration exercise program→ 8 w Subgroup analysis→NR programme can
to 4 yrs Total # of exercise sessions→24 Adverse events→ None have an
Gender→ Format→individual improvement on
Exercise group: Female 86.1% Setting→home Results mental health
Control: Female 65.7 % Deliverer→ not led by professional Exercise group reported significant over the same
Age→ mean (SD) yrs Adherence→ 89% completed at least improvements in sleep quality (p < 0.01) period of time.
Exercise group: 47.36 (10.14) 50% of intervention (20 sessions and the mental health dimension of QoL (p
Control group: 56.37 (12.43) completed +/-6.6) < 0.01)
Ethnicity→NR
Education → exercise: 9.97 Control group: Within exercise group, enhanced sleep
(3.67); control 6.37 (12.43) Instructed to maintain current quality was significantly associated with
SES→NR lifestyle, record any extra physical reduced bodily pain (p = 0.04) and time
Employment status→ exercise: activity. They could join walking had an effect over the mental health
unemployed 23, 63.9%; control programme after 8 weeks of dimension of QoL (p < 0.01).
25, 71.4% intervention conclusion
Comorbidities→ NR
30
Study design Components of
Country intervention
Wang, 2011 N=72; I=35; C=37 Exercise intervention: Primary → QoL: Nurses, depending
Cancer Type→breast, stage I&II Walking + HR monitor + - HRQoL (FACT-G) on skill and
RCT Time in active ttm→ followed pedometer + w phone call - Fatigue (FACIT-F) knowledge, can
participants from 24 hrs before + w meeting + w - Quality of sleep (PSQI) encourage PA,
Taiwan surgery to end of chemo cycle (6w) recording PA diary + role - Exercise self-efficacy (exercise self-efficacy scale)
refer patients to
- PA behaviour (GLTEQ)
Gender→ female model to increase self- rehab programs,
- CRF (6MWT)
Age→ Exercise group: 48.4 (10.15) efficacy prescribe and
Measures and follow-up→ baseline, 2-3 w after surgery
Control group: 52.3 (8.84) Type →aerobic (2nd baseline), 4w, and 6w monitor exercise
Ethnicity→NR and SES→NR Intensity→ HR max 40- Retention→ 100% (control 2 dropped out at baseline, 35 in breast cancer
Education → exercise: high school, 60% continued until the end) populations
12 (34.3%); college, 12 (34.4%); Frequency→3-5 d/w Subgroup analysis→none
graduate, 6 (17.1%) Duration →30 min Adverse events→exercise: 2 participants with anaemia A walking
Control: high school, 13 (35. Duration exercise and dizziness during programme / Control: 3 adverse, 1 programme helped
1%); college, 14 (37.8%); graduate, program→ 6w discomfort, 1 dizziness, 1 dyspnoea women with
1 (2.7%) Total # of exercise Results cancer go through
Employment status→ exercise: sessions→18-30 sessions QoL (FACT-G) had a significant better improvement over treatment more
unemployed, 8 (22.9%); full-time, Format→individualised the 4 follow-up measures vs usual care (p=0.001) easily, it gave them
20 (57.1%); control: unemployed, Setting→home Sleep disturbances were significantly reduced in the something to focus
10 (27.0%); full-time, 17 (45.9%) Deliverer→ not led by exercise group vs usual care (p=0.001) during the on, someone to
Comorbidities and hormone professional intervention period support them, and
therapy→ NR Adherence→ 1 (3.3%) Exercise self-efficacy was significantly different at they were not
Past exercise history→exercise: did not comply with low - baseline ((p=0.04) higher in exercise group) but had a alone during their
exercise before surgery, 77 min moderate intensity constant and much rapid growth in exercise group cancer journey
(138); now 67.71 min (127.35) exercise; 2 (6.7%) did less compared to usual care during the intervention period
Control: exercise before 94.46 min than 3 sessions/w; 2 (p<0.001) This intervention
Fatigue was significant within both groups, and between
(126.41); now 66.89 min (109.60) (6.7%), did less than 30 strengthens the
groups difference was significant only at week 4 and 6
Type of exercise done before min/session evidence that PA is
(p<0.001)
Exercise: none, 11 (31.4%); walk, Control group: one of the main
Self-reported exercise behaviour during the last week
15 (42.9%); fast walk, 5 (14.3%); Usual care coping
was significantly increased by the exercise programme
mountain climbing, 1 (2.9%) Contamination: 30.4% (n mechanisms
compared to usual care (p=0.038)
Control: none, 12 (32.4%); walk, = 10) during the 6w period women with
CRF by 6MWT significantly improved in exercise group
12 (32.4%); fast walk, 3 (8.1%); - individuals who exercised breast cancer use
and walked significantly farther vs usual care after the
mountain climbing, 3 (8.1%); yoga, more than 3 x/w and 30 to go through their
interv /Adjusted mean differences between groups was
2 (5.4%); tai-chi, 2 (5.4%) min/session cancer journey
20.85 m (P = .001) at w 2-3 and 32.75 m (P = .001) at w4
31
Country
Windsor, 2004 N=66; I=33; C=33 Exercise intervention: Primary outcome→ None identified Advice to rest
Cancer Type→prostate (51 Continuous walking at home Secondary→ - Fatigue (BFI) when feeling
RCT of 65 with tumours T1 to T2 Type → aerobic - Resting HR fatigued showed a
Intensity→ HR max 60-70% - Exercise HR (shuttle test) slight
UK Time since cancer Frequency→ 3d/w - PA (SPAQ) deterioration in
diagnosis→NR Duration → 30min physical
Duration exercise program→ until Measures and follow-up→ baseline, after functioning and a
Gender→ male end of therapy 5,10,15, and 20 fractions of radiation, at follow- significant
Age→ mean (SD) yrs Total # of exercise sessions→ varied up at 4w after completion of ttm increase in fatigue
Exercise group: 68.3 (0.9) Format→individualised Retention→ exercise 32 and control 33 at all at the end of
Control group: 69.3 (1.3) Setting→home measures radiotherapy in
Ethnicity→NR Deliverer→ unclear Subgroup analysis→none prostate patients
Education → NR Adherence→ 100% recorded 90 Adverse events→ none
SES→NR min of exercise at advised intensity Home-based,
Employment status→NR Results moderate-
Comorbidities→ NR Control group: No significant between group differences in intensity walking
Past exercise history→NR Advised that rest is best fatigue scores at baseline before radiation (P = produced a
Hormone 0.55) or after 4 weeks of radiotherapy (P = 0.18). significant
therapy→exercise: 27% Control group had significant increases in fatigue improvement in
receiving adjuvant hormone scores from baseline to the end of radiotherapy physical
therapy for high-risk (P = 0.013), with no significant increases functioning with
tumours; control 30% observed in the exercise group (P = 0.203). no significant
increase in fatigue
No significant differences between groups for
shuttle test. Exercise group had a significant Improving
increase (13.2%) in distance walked (P = physical
0.0003). Control group had no significant functioning can be
reduction (2.4%) in shuttle test distance at the an effective way to
end of radiotherapy. combat radiation
fatigue in patients
affected by
prostate cancer
32
Reference Population Methods/ Outcomes (measurement tool) Conclusions
Study design Components of intervention and Results
Country
Yang, 2011 N=44; I=19; C=21 Exercise intervention: Regular moderate-
Cancer Type→breast cancer 5 min warm up + 30 min brisk walking + Primary outcome→ QoL intensity exercise,
RCT receiving chemo after surgery 5 min cool down - Symptom severity (MDASI- such as walking at 60-
Exercise: Stage I, 9 (47.4%);II, 10 Type →aerobic Taiwanese Version) 80% HR max,
Taiwan (52.6%); control: Stage I, 6 Intensity→ HR max 60-80% - Emotional distress (POMS- improves treatment-
(28.6%); II, 12 (57.1%); IIIa, 3 Frequency→ 3x/w SF) related symptoms
(14.3%) Duration → 30-40min Others: and mood in women
Active treatment of 12w in Duration exercise program→ 12 w - Self-reported PA level (7-Day with breast cancer
chemotherapy postoperatively during chemotherapy PA recall)
Gender→ female Total # of exercise sessions→36 Home-based walking
Age→ mean (SD) yrs sessions Measures and follow-up→ exercise programme
Exercise group: 50.79(7.05) Format→individual baseline, 6w, and 12 w can be easily
Control group: 52.71 (8.11) Setting→home Retention→ 100% incorporated into
Ethnicity→NR Deliverer→ not led by professional Subgroup analysis→None care for women with
Education → NR Adherence→ attendance to prescribed Adverse events→ None reported breast cancer
SES→NR exercise sessions 77% (31/36) undergoing
Employment status→exercise: Achieved intensity prescription 100% Results chemotherapy
employed 15.8% Women in the exercise group
Control 38.1% Control group: reported significantly lower
Comorbidities→ NR Advised to maintain current lifestyle symptom severity scores and
Past exercise history→NR mood disturbance compared with
Hormone therapy→NR those in the control group
throughout the study period.
Abbreviations: 12-MWT=12 minute walking test; ACSM=American College of Sports Medicine; AML=acute myelogenous leukemia; BDI=Beck’s depression
inventory; BFI=Brief Fatigue Inventory; C=control; CES-D=Center for Epidemiological Studies Depression scale; COPD=Chronic Obstructive Pulmonary Disease;
CRF=Cardio respiratory fitness; CVD=Cardiovascular disease; d=day; EWB=emotional well-being; FACT=Functional Assessment of Cancer Therapy; FACT-
B=breast; FACT-cog=cognitive function; FACT-ES=endocrine symptoms; FACT-F=fatigue; FACT-G=general; FWB=Functional well-being; HL=Hodgkin
lymphoma; HR=Heart rate; I=Intervention; MDASI-T=M.D. Anderson Symptom Inventory-Taiwanese Version; N=population sample size; NHL=non-Hodgkin
lymphoma; NR= Not reported; PFS=Piper Fatigue Scale; POMS=Profile of Mood States; PSQI= Pittsburgh Sleep Quality Inventory; PSQI=Pittsburgh Sleep Quality
Inventory; QoL= Quality of life; RCT=Randomized control trial; SD=standard deviation; SES=Self-esteem scale; SF=Short form; SF-36 = Medical Outcomes
Survey Short Form-36; SPAQ=Scottish Physical Activity Questionnaire; STAI=State-Trait Anxiety Index; SWB=social, family well-being; SWLS=Satisfaction with
Life Scale; w=week; WOMAC= Western Ontario and McMaster Universities Osteoarthritis Index; x=times;
33

A Systematic Search and Narrative Review of The Literature.: Yanaina Chavez Ugalde

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A systematic search and narrative review of the literature.

Macmillan Cancer Support

Yanaina Chavez Ugalde

✓ To explore the effectiveness of walking interventions across different types of

✓ To explore BCTs used in walking interventions and assess if these enhanced

“Walk intervention” OR “Walking intervention”

“Cancer” OR “neoplasm$” OR “tumor$” OR “tumour$” OR “malignan$” OR “cancer

“quality of life” OR “health status” OR “activities of daily living” OR “pain” OR “fatigue” OR

o Functional capacity is considered one of the most important outcomes in the

✓ Physical activity – objective (accelerometers/pedometers) or self-reported

✓ Stage of motivational readiness for physical activity / Exercise self-efficacy

✓ Adverse events (e.g. breathlessness, dizziness, nausea)

✓ Intervention/programme duration (weeks): duration of programmes varied

✓ Total number of sessions: interventions averaged a total of 41.5 sessions with a

✓ Programme setting [home-based (self managed) /facility-based (supervised)]:

✓ Adherence: Each study defined adherence differently, such as completing >50% of

Effect of walking interventions over outcomes

Physical activity levels (self-reported questionnaires) were examined in six interventions

✓ When designing walking interventions, or walking programmes to improve health

✓ Walking can be considered to be a moderate-to-vigorous intensity activity (achieving

✓ Having a significant increase in functional capacity (e.g. walking distance), is highly

✓ Adherence to walking sessions in people affected by cancer is high (>50%-100%),

✓ An increase in physical activity level can be achieved through a walking intervention.

✓ Providing 1 or 2 days of weekly walking guided sessions, during a 12 week

No significant differences for anxiety

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