Abstract
Purpose
The COVID-19 pandemic has imposed additional barriers to physical activity (PA) in cancer survivors. Adaptations to PA programmes are needed during the pandemic. Therefore, the purpose of this study was to evaluate (1) the PA preferences of cancer survivors prior to and during the pandemic and (2) the available resources to engage in PA during the pandemic.
Methods
Using a cross-sectional study design, cancer survivors were recruited globally to participate in a self-administered survey assessing their PA preferences and available PA resources during the pandemic. Descriptive statistics were used to determine trends in PA preferences and resources. A sub-group analysis was conducted for age, gender, education, and PA levels.
Results
Cancer survivors (N = 493) were mainly women (70.4%) diagnosed with breast cancer (29.0%), with a mean age of 48.7 ± 15.8 years, and 87.1 ± 81.9 months since diagnosis. Since the start of the pandemic, cancer survivors were primarily walking (82.6%), and performing PA alone (62.7%) and at home (46.6%). Sub-group analysis revealed education level, PA levels, and age to be associated with significant differences in PA preferences. The most common equipment available to survivors in their homes were exercise mats (40.6%) and free weights (39.8%). Few survivors were made aware of at-home PA resources (19.1%), and approximately half indicated wanting to receive these resources (49.6%).
Conclusions
Understanding cancer survivors’ preferences and resources for PA during the pandemic is critical to designing effective home-based interventions. Interventions and recommendations should be tailored based on the level of education and PA participation, as well as age.
Keywords: Cancer, Physical activity, Preferences, COVID-19
Background
Physical activity (PA) is an effective self-management strategy to improve several cancer-related health outcomes (e.g. cancer-related fatigue, physical functioning, quality of life) [1–5]. PA guidelines recommend that cancer survivors perform 30 min of moderate aerobic activity 3 times/week for at least 8–12 weeks and 2 days/week of strength training for improvements in cancer-related health outcomes; however, 150 min/week of aerobic PA is beneficial for general health benefits among cancer survivors [5]. Despite the benefits of PA, cancer survivors face many barriers to engaging in PA, with the majority not performing sufficient PA pre-pandemic to achieve the associated health benefits [6–12]. Common barriers pre-pandemic included treatment-related side-effects, fatigue, lack of time and motivation, and lack of accessibility of PA programmes (i.e. cost, availability) [13–17].
The COVID-19 pandemic and its prevention measures have imposed additional barriers for PA in cancer survivors. Moreover, cancer survivors are at an increased risk when contracting the virus [18], posing additional barriers to their participation. This is evidenced by a reduction in self-perceived PA levels during the pandemic across several studies [19–22]. As this population had low levels of PA prior to the pandemic, this further decrease in PA is of concern. Adaptations to PA programmes and resources are needed.
Understanding cancer survivors’ preferences towards PA is important to increasing participation. Pre-pandemic, cancer survivors reported preferences for home-based PA, particularly walking, moderate intensity, and unsupervised PA [12–14, 17]. With the additional barriers imposed from the pandemic, understanding these preferences during the pandemic is critical to designing effective PA interventions to help cancer survivors increase and maintain PA levels. Therefore, the purpose of this study was to evaluate (1) the PA preferences of cancer survivors prior to and since the start of the pandemic; (2) examine demographic and clinical subgroups associated with these preferences; and (3) the available resources to engage in PA during the pandemic.
Methods
Design
A secondary analysis of a global, cross-sectional self-administered survey via REDCap was performed between July and November 2020. Ethics approval was obtained from the University of Toronto’s Research Ethics Board (#00039412) and informed consent was completed prior to survey completion.
Study participants
Eligibility criteria included (a) cancer survivors 18 years of age or older, (b) diagnosed with any cancer type, and (c) able to complete the study in English. Cancer survivors were recruited globally through convenience sampling using Prolific (www.prolific.co; an online survey distribution tool). In addition, cancer survivors were recruited from an existing database of cancer survivors, social media, and community cancer organizations.
Measures
Demographic and clinical characteristics
Typical demographic (e.g. age, gender) and clinical (e.g. cancer type, treatment type) characteristics were collected.
COVID-19 prevention measures
COVID-19 prevention measures enacted in survivors’ location of residence were assessed using researcher-generated questions. This included measures in place to reduce the spread in their area (e.g. complete lockdown, stay-at-home, physical distancing) and measures that they had personally taken for personal health and safety (e.g. physical distancing, self-isolation due to potential exposure).
PA behaviour
Preferences for activities (e.g. walking, cycling), location to engage in PA (e.g. gym, home), and preferred company (e.g. alone, with a friend) to engage in PA prior to and since the start of the pandemic were measured. These questions were researcher-generated and informed by previous research [12, 14].
PA awareness
Awareness of PA resources since the start of the pandemic was measured using researcher-generated questions and informed by previous research [23]. Healthcare provider PA discussions and recommendations were assessed, including the type of recommendations made (i.e. frequency, intensity, type). Awareness of at-home PA resources were also assessed including whether the resources were cancer specific and interest in receiving these resources.
PA environment
The PA environment was measured using questions that were researcher-generated and informed by previous research [24]. Measures included the type of home they lived in (e.g. house, apartment), available spaces in their home (e.g. home gym, living room), and neighbourhood (e.g. walking paths, city park) for PA. Available exercise equipment for PA (e.g. cardio equipment, free weights) was also assessed.
Statistical analysis
Statistical analyses were performed using SPSS 28 (IBM Corp., Toronto, Canada). Descriptive statistics, including frequencies and percentages of responses, were used to determine trends in PA preferences and resources. Careless responders were removed using the Careless R package [25]. Responses with a longstring index greater than half of the number of items on a given scale, a Mahalanobis distance of < 3.0, or a negative correlation on psychometric synonyms were considered to be high risk of careless responding for individual scales [26, 27]. In the current study, responses flagged as a high risk of careless responding on at least two independent scales were excluded.
A sub-group analysis for PA preferences was also conducted. Demographic (i.e. age, gender, relationship status, employment status, education level), medical (i.e. months since diagnosis, treatment status, months since treatment, cancer spread), and COVID-19-related variables (i.e. government-mandated and personal prevention measures) that might influence PA preferences were dichotomized. For continuous variables, a mean split was used for dichotomization, except for PA levels, where groups were dichotomized based on meeting the PA guidelines of 150 min of aerobic PA. An exploratory analysis was performed, and variables associated with significant differences in at least 20% of PA preferences were included in the sub-group analysis. Chi-square tests were performed to assess differences in frequencies between these groups. Statistical significance was set to a level of p < 0.05.
Results
Participant flow through the study has been previously reported [28]. In brief, of 580 participant responses that met the eligibility criteria, 511 provided complete PA and preference data for both before and during the pandemic. Of these, 18 were at a high risk of careless responding leaving 493 responses to be included in the current analysis.
Demographic, medical, and COVID-19-related variables are presented in Table 1. Cancer survivors were primarily women (70.4%), with a mean age of 48.7 ± 15.8 years, diagnosed with breast (29.0%) cancer, and a mean of 87.1 ± 81.9 months since diagnosis. Cancer survivors were primarily from the UK (37.9%), the USA (22.9%), and Canada (20.9%). Government-mandated prevention measures at the time of study assessment included physical distancing (94.3%) and suggested/mandatory stay-at-home (52.9%). Similarly, personal prevention measures taken were most commonly physical distancing (90.3%).
Table 1.
Demographic, medical, and COVID-19 characteristics of cancer survivors (N = 493)
| Variable | Mean ± SD or n (%) |
|---|---|
| Demographic | |
| Age (years) | 48.7 ± 15.8 |
| Gender | |
| Women | 347 (70.4) |
| Men | 143 (29.0) |
| Self-identify | 2 (0.4) |
| Ethnicity | |
| White | 443 (89.9) |
| Asian | 17 (3.4) |
| Latin American | 10 (2.0) |
| Black | 8 (1.6) |
| Other | 10 (2.0) |
| Education | |
| Some/completed high school | 89 (18.1) |
| Some/completed university/college/graduate | 403 (81.7) |
| Employment | |
| Full Time | 179 (36.3) |
| Part-time | 105 (21.3) |
| Unemployed | 209 (42.4) |
| Medical | |
| Cancer type | |
| Breast | 143 (29.0) |
| Urologic | 72 (14.6) |
| Hematologic | 59 (12.0) |
| Gynecologic | 57 (11.6) |
| Skin | 45 (9.1) |
| Thyroid | 24 (4.9) |
| Colorectal | 21 (4.3) |
| Lung | 11 (2.2) |
| Head and neck | 10 (2.0) |
| Other | 49 (9.9) |
| Months since diagnosis | 87.1 ± 81.9 |
| Disease stage | |
| Localized | 399 (80.9) |
| Metastatic | 78 (15.8) |
| Unsure | 14 (2.8) |
| Months since last treatment | 58.8 ± 77.5 |
| COVID-19 variables | |
| Geographic location | |
| UK | 187 (37.9) |
| USA | 113 (22.9) |
| Canada | 103 (20.9) |
| European Union country | 43 (8.7) |
| Australia | 7 (1.4) |
| South Africa | 7 (1.4) |
| Other | 33 (6.7) |
| Government-mandated prevention measuresa | |
| Complete lockdown | 29 (5.9) |
| Mandatory/suggested stay-at-home | 261 (52.9) |
| Physical distancing | 465 (94.3) |
| Other | 78 (15.8) |
| None | 4 (0.8) |
| Personal prevention measuresa | |
| Physical distancing | 445 (90.3) |
| Self-isolate | 138 (28.0) |
| Other | 22 (4.5) |
| None | 14 (2.8) |
aCould indicate more than one response
Four variables (i.e. age, gender, education level, and PA levels) were found to have significant differences in 20% or more of PA preference and were included in sub-group analysis.
PA preferences prior to the pandemic and sub-group analyses
Overall and subgroup-specific PA preferences are demonstrated in Tables 2 and 3. Prior to the COVID-19 outbreak in their region, cancer survivors were primarily walking (86.8%) and preferred to perform PA at home (27.6%) or outdoors (26.6%), and alone (46.0%). However, there were differences in preferences based on education level, PA levels, and age. A greater percentage of cancer survivors with any college education (i.e. any partial or completed college/university/graduate education) compared to those without one preferred walking (88.6% vs. 77.5%; p = 0.007), and PA outdoors (28.6% vs. 16.3%; p = 0.022) and alone (48.7% vs. 32.5%; p = 0.015). Walking was also preferred more in those meeting the PA guidelines compared to those not meeting them (91.5% vs. 82.5, p = 0.003). Further, PA performed outdoors was preferred more in those ≥ 49 vs. those < 49 (32.1% vs. 21.3%; p = 0.008).
Table 2.
Overall and sub-group-specific physical activity preferences of cancer survivors before the start of the pandemic (N = 493)
| Outcomes | Overall n (%) |
Demographic and medical subgroup preferences | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Moderator | Group | n | % | Group | n | % | p | ||
| Activity preferences | |||||||||
| Walking | 428 (86.8) | Age | ≥ 49 | 218 | 88.6 | < 49 | 195 | 84.8 | 0.217 |
| Gender | Women | 306 | 88.2 | Men | 121 | 84.6 | 0.283 | ||
| College education | Yes | 366 | 88.6 | No | 62 | 77.5 | 0.007 | ||
| Physically active | Yes | 216 | 91.5 | No | 212 | 82.5 | 0.003 | ||
| Flexibility exercises | 105 (21.3) | Age | ≥ 49 | 54 | 22.0 | < 49 | 50 | 21.7 | 0.955 |
| Gender | Women | 75 | 21.6 | Men | 30 | 21.0 | 0.876 | ||
| College education | Yes | 87 | 21.1 | No | 18 | 22.5 | 0.774 | ||
| Physically active | Yes | 62 | 26.3 | No | 43 | 16.7 | 0.010 | ||
| Cycling | 102 (20.7) | Age | ≥ 49 | 43 | 17.5 | < 49 | 56 | 24.3 | 0.065 |
| Gender | Women | 60 | 17.3 | Men | 41 | 28.7 | 0.005 | ||
| College education | Yes | 84 | 20.3 | No | 18 | 22.5 | 0.662 | ||
| Physically active | Yes | 69 | 29.2 | No | 33 | 12.8 | < 0.001 | ||
| Resistance training | 98 (19.9) | Age | ≥ 49 | 45 | 18.3 | < 49 | 50 | 21.7 | 0.347 |
| Gender | Women | 71 | 20.5 | Men | 27 | 18.9 | 0.691 | ||
| College education | Yes | 88 | 21.3 | No | 10 | 12.5 | 0.071 | ||
| Physically active | Yes | 69 | 29.2 | No | 29 | 11.3 | < 0.001 | ||
| Swimming | 92 (18.7) | Age | ≥ 49 | 50 | 20.3 | < 49 | 39 | 17.0 | 0.346 |
| Gender | Women | 67 | 19.3 | Men | 23 | 16.1 | 0.402 | ||
| College education | Yes | 75 | 18.2 | No | 17 | 21.3 | 0.516 | ||
| Physically active | Yes | 55 | 23.3 | No | 37 | 14.4 | 0.011 | ||
| Yoga | 86 (17.4) | Age | ≥ 49 | 31 | 12.6 | < 49 | 54 | 23.5 | 0.002 |
| Gender | Women | 79 | 22.8 | Men | 7 | 4.9 | < 0.001 | ||
| College education | Yes | 77 | 18.6 | No | 9 | 11.3 | 0.111 | ||
| Physically active | Yes | 52 | 22.0 | No | 34 | 13.2 | 0.010 | ||
| Running | 84 (17.0) | Age | ≥ 49 | 27 | 11.0 | < 49 | 57 | 24.8 | < 0.001 |
| Gender | Women | 49 | 14.1 | Men | 35 | 24.5 | 0.006 | ||
| College education | Yes | 66 | 16.0 | No | 18 | 22.5 | 0.156 | ||
| Physically active | Yes | 60 | 25.4 | No | 24 | 9.3 | < 0.001 | ||
| Exercise classes | 77 (15.6) | Age | ≥ 49 | 36 | 14.6 | < 49 | 40 | 17.4 | 0.412 |
| Gender | Women | 68 | 19.6 | Men | 9 | 6.3 | < 0.001 | ||
| College education | Yes | 70 | 16.9 | No | 7 | 8.8 | 0.064 | ||
| Physically active | Yes | 53 | 22.5 | No | 24 | 9.3 | < 0.001 | ||
| Playing sports | 53 (10.8) | Age | ≥ 49 | 25 | 10.2 | < 49 | 27 | 11.7 | 0.582 |
| Gender | Women | 24 | 6.9 | Men | 29 | 20.3 | < 0.001 | ||
| College education | Yes | 44 | 10.7 | No | 9 | 11.3 | 0.875 | ||
| Physically active | Yes | 31 | 13.1 | No | 22 | 8.6 | 0.101 | ||
| Location preferences | |||||||||
| At home | 136 (27.6) | Age | ≥ 49 | 62 | 25.2 | < 49 | 73 | 31.7 | 0.114 |
| Gender | Women | 96 | 27.7 | Men | 39 | 27.3 | 0.929 | ||
| College education | Yes | 111 | 26.9 | No | 25 | 31.3 | 0.423 | ||
| Physically active | Yes | 58 | 24.6 | No | 78 | 30.4 | 0.152 | ||
| Outdoors | 131 (26.6) | Age | ≥ 49 | 79 | 32.1 | < 49 | 49 | 21.3 | 0.008 |
| Gender | Women | 98 | 28.2 | Men | 33 | 23.1 | 0.240 | ||
| College education | Yes | 118 | 28.6 | No | 13 | 16.3 | 0.022 | ||
| Physically active | Yes | 71 | 30.1 | No | 60 | 23.3 | 0.091 | ||
| Gym | 69 (14.0) | Age | ≥ 49 | 26 | 10.6 | < 49 | 39 | 17.0 | 0.043 |
| Gender | Women | 48 | 13.8 | Men | 20 | 14.0 | 0.964 | ||
| College education | Yes | 61 | 14.8 | No | 8 | 10.0 | 0.260 | ||
| Physically active | Yes | 35 | 14.8 | No | 34 | 13.2 | 0.609 | ||
| Preferences for company | |||||||||
| Alone | 227 (46.0) | Age | ≥ 49 | 108 | 43.9 | < 49 | 113 | 49.1 | 0.286 |
| Gender | Women | 161 | 46.4 | Men | 65 | 45.5 | 0.836 | ||
| College education | Yes | 201 | 48.7 | No | 26 | 32.5 | 0.015 | ||
| Physically active | Yes | 105 | 44.5 | No | 122 | 47.5 | 0.409 | ||
| With a spouse | 60 (12.2) | Age | ≥ 49 | 39 | 15.9 | < 49 | 21 | 9.1 | 0.025 |
| Gender | Women | 38 | 11.0 | Men | 22 | 15.4 | 0.175 | ||
| College education | Yes | 47 | 11.4 | No | 13 | 16.3 | 0.179 | ||
| Physically active | Yes | 27 | 11.4 | No | 33 | 12.8 | 0.589 | ||
| With a friend | 52 (10.5) | Age | ≥ 49 | 28 | 11.4 | < 49 | 19 | 8.3 | 0.242 |
| Gender | Women | 38 | 11.0 | Men | 13 | 9.1 | 0.536 | ||
| College education | Yes | 47 | 11.4 | No | 5 | 6.3 | 0.199 | ||
| Physically active | Yes | 24 | 10.2 | No | 28 | 10.9 | 0.748 | ||
Table 3.
Overall and sub-group-specific physical activity preferences of cancer survivors since the start of the pandemic (N = 493)
| Type of activity | Overall n (%) |
Demographic and medical subgroup preferences | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Moderator | Group | n | % | Group | n | % | p | ||
| Walking | 407 (82.6) | Age | ≥ 49 | 209 | 85.0 | < 49 | 183 | 79.6 | 0.123 |
| Gender | Women | 291 | 83.9 | Men | 113 | 79.0 | 0.200 | ||
| Physically active | Yes | 181 | 90.5 | No | 226 | 77.1 | < 0.001 | ||
| Cycling | 94 (19.1) | Age | ≥ 49 | 43 | 17.5 | < 49 | 47 | 20.4 | 0.411 |
| Gender | Women | 61 | 17.6 | Men | 32 | 22.4 | 0.218 | ||
| Physically active | Yes | 59 | 29.5 | No | 35 | 11.9 | < 0.001 | ||
| Flexibility exercises | 89 (18.1) | Age | ≥ 49 | 46 | 18.7 | < 49 | 42 | 18.3 | 0.902 |
| Gender | Women | 58 | 16.7 | Men | 31 | 21.7 | 0.195 | ||
| Physically active | Yes | 47 | 23.5 | No | 42 | 14.3 | 0.009 | ||
| Running | 77 (15.6) | Age | ≥ 49 | 28 | 11.4 | < 49 | 48 | 20.9 | 0.005 |
| Gender | Women | 43 | 12.4 | Men | 34 | 23.8 | 0.002 | ||
| Physically active | Yes | 53 | 26.5 | No | 24 | 8.2 | < 0.001 | ||
| Yoga | 76 (15.4) | Age | ≥ 49 | 22 | 8.9 | < 49 | 54 | 23.5 | < 0.001 |
| Gender | Women | 73 | 21.0 | Men | 3 | 2.1 | < 0.001 | ||
| Physically active | Yes | 38 | 19.0 | No | 38 | 13.0 | 0.069 | ||
| Resistance training | 71 (14.4) | Age | ≥ 49 | 34 | 13.8 | < 49 | 36 | 15.7 | 0.573 |
| Gender | Women | 49 | 14.1 | Men | 22 | 15.4 | 0.718 | ||
| Physically active | Yes | 41 | 20.5 | No | 30 | 10.2 | 0.001 | ||
| Bed/chair exercises | 50 (10.1) | Age | ≥ 49 | 25 | 10.2 | < 49 | 23 | 10.0 | 0.953 |
| Gender | Women | 38 | 11.0 | Men | 12 | 8.4 | 0.395 | ||
| Physically active | Yes | 17 | 8.5 | No | 33 | 11.3 | 0.318 | ||
PA preferences since the start of the pandemic and sub-group analyses
During the pandemic, walking was the most preferred type of PA (82.6%). Contrary to prior to the pandemic, walking was preferred more in those not meeting the PA guidelines compared to those meeting them (77.1% vs. 90.5, p = < 0.001). Moreover, since the start of the pandemic, cancer survivors had been primarily performing PA at home (46.6%) or outdoors/around their neighbourhood (33.1%), and alone (63.6%).
PA environment
Almost half of the survivors lived in single-detached homes (46.9%), with space to perform PA in their living room (65.9%). In their neighbourhood, they were able to perform PA safely (i.e. maintaining adequate physical distancing) on sidewalks (63.1%), streets (55.0%), walking paths (53.5%), and city parks (44.6%). The most common equipment available to survivors in their homes were exercise mats (40.6%), free weights (39.8%), stairs (34.7%), resistance bands (33.5%), a wearable activity tracker (32.7%), and cardio equipment (28.2%).
Awareness of PA
Awareness of PA demonstrated that few survivors had received a PA recommendation from a healthcare provider since the start of the pandemic (21.9%). Of those that had received a recommendation, this recommendation came primarily from oncologists (35.5%), family physicians (29.0%), and nurses/nurse practitioners (15.0%). Healthcare providers commonly recommended walking (84.1%) to cancer survivors. Moreover, they were mainly recommended to perform moderate intensity PA (53.3%), for a mean of 34 (SD = 21) minutes/session, 4 (SD = 2) days per week. Light intensity was also recommended to 24.3% of survivors. Further, approximately half of cancer survivors were interested in receiving at-home PA resources for home-based exercise (49.6%). However, few survivors had been made aware of at-home PA resources since the start of the pandemic (19.1%), and of these, few of these resources were cancer specific (19.1%). Cancer survivors were most commonly made aware of PA resources through websites/internet (55.3%), social media (45.7%), and word of mouth (33.0%).
Discussion
This study provides insights into the PA preferences and resources available to cancer survivors prior to and since the start of the pandemic. Since the start of the pandemic, cancer survivors have preferred walking activities and primarily performed activity at home or outdoors and alone. These preferences are similar to previous studies pre-pandemic that have found cancer survivors to prefer PA performed at home, alone, and walking for the modality [12, 13, 29]. Prior to the start of the pandemic, performing PA at home was the most preferred location for 27.6% of cancer survivors. Since the start of the pandemic, performing PA at home was the primary location in 46.6% of cancer survivors. Thus, the preferences seen pre-pandemic were increased during the pandemic. These findings are also similar to Faro et al. [19] that found cancer survivors to primarily prefer indoor or outdoor activities performed alone during the pandemic.
Further, sub-group analyses revealed education level, PA levels, and age to be associated with significant differences in PA preferences. PA recommendations and interventions should be tailored to cancer survivors, with awareness of the type of activity preferred across the different groups. Previous work has found age to be associated with decreased moderate-to-vigorous PA [22, 30, 31] and education to be associated with increased PA [22, 31]. The findings from the present study also found age and education to be associated with differences in PA preferences. These findings can be used to design tailored interventions for older cancer survivors, without a college education, who are at a greater risk of decreased PA.
As home-based PA was preferred prior to the pandemic, home-based interventions will still be valuable even as we shift from a pandemic to an endemic. Home-based interventions, delivered using telehealth tools (e.g. video, phone, wearable monitors, mobile apps) [32] provide access to those living in rural areas with a lack of access to programming and facilities, as well as overcome barriers of travel, time, and cost [13–17]. Specifically, telehealth exercise interventions are useful for delivering exercise instructions and supervision [33]. A study assessing the delivery of virtual cancer rehabilitation during the pandemic found high attendance rates of 80–93% with virtual delivery of programmes, and an increase in the number of completed visits compared to in-person visits prior to the pandemic [34]. A potential lack of exercise equipment and lack of space at home were proposed as disadvantages to home-based exercise interventions [35]. This is similar to telehealth exercise interventions for cancer survivors, where a lack of equipment available at home is a key challenge to delivering these types of interventions to cancer survivors [33]. The findings in the present study provide insights into the resources available to cancer survivors to perform PA at home. The majority of cancer survivors did have space to perform PA at home or outdoors. They also had home exercise equipment such as exercise mats and free weights available. The majority of cancer survivors (86.6%) had at least one type of equipment available for exercise. Thus, equipment and space are not disadvantages to home-based PA. As studies have found the environment to be associated with PA including having home equipment, understanding the environment available to cancer survivors will allow for better recommendations and tailored and effective home-based PA resources and interventions [24, 36].
Awareness of PA resources is also a key strategy in improving the PA behaviour of cancer survivors. Results demonstrated a need for increased awareness of at-home PA resources among cancer survivors, with few cancer survivors made aware of any (19.1%), and of those made aware only 19.1% were cancer-specific resources. However, approximately half of cancer survivors expressed interest in receiving these resources. These resources are increasingly important during a pandemic when they face additional barriers in addition to cancer-related barriers. Clinicians have been recommended as a key component to improve the accessibility of PA and bridge the gap between patient and exercise resources [37]. Referral pathways have been developed to outline steps for the clinician (e.g. medical doctors, nurses) to connect patients to exercise-related resources, including Santa Mina et al. [37] and Schmitz et al. [38]. The clinician holds a critical role in these pathways as they are the first step in either referring patients to PA programing or offering them self-management resources.
In addition to clinicians being well positioned to improve awareness of PA resources for cancer survivors, their recommendations are associated with positive changes to PA behaviour. Cancer survivors have expressed wanting to receive PA information from healthcare providers, particularly their oncologist, and that they would be motivated to exercise if recommended by their oncologist [12, 13, 15, 17, 39, 40]. PA information from a healthcare professional, including from oncology clinicians, has also been found to be associated with increased self-reported PA levels of cancer survivors [11, 39, 41]. Despite this, only 21.9% received any discussion and/or recommendation from a healthcare provider. Of those that did receive some discussion and/or recommendation, the recommendations included activity to be performed 4 days/week. The updated guidelines for cancer survivors are to perform moderate-intensity aerobic activity for 30 min 3 days per week. Ensuring clinicians provide recommendations that meet the PA guidelines are important, as they require less PA for improvements specific to cancer survivors and are therefore more achievable. Despite recommendations close to those of the guidelines, this was only provided to few cancer survivors. Having a healthcare provider recommendation, particularly from an oncology clinician, will support cancer survivors’ PA behaviour change, in addition to increasing awareness of PA resources discussed above. Therefore, enhancing the roles of clinicians in PA promotion is important.
Study limitations
To the best of our knowledge, this is the first study assessing the PA preferences of cancer survivors during the COVID-19 pandemic that was widely distributed to a global sample of cancer survivors. However, there are limitations to the present study. For one, the assessment of pre-pandemic PA preferences may be subject to recall bias. However, findings were similar to previous studies prior to the pandemic. Further, the study sample was primarily White women diagnosed with breast cancer, and therefore may not be generalizable to the broader cancer survivor population.
Clinical implications
Cancer survivors had a preference for home-based PA prior to and since the start of the pandemic, and the present study demonstrated the majority to have access to space and equipment to facilitate this. The specific resources available to cancer survivors can be used to inform home-based interventions. Further, the present study demonstrated a lack of awareness of such interventions and resources. Efforts to increase awareness are needed to facilitate PA participation, with clinicians being well-positioned to help promote PA.
Conclusion
As PA levels in cancer survivors were low prior to the pandemic, the decrease in PA during the pandemic is of concern. Cancer survivors have the potential to improve several cancer-related health outcomes with regular PA, including their quality of life and physical functioning [5]. However, they face unique barriers further complicated with the challenges of a pandemic. As PA behaviour change is complex and challenging, the findings of this study of the preferences and available environment for PA will help facilitate PA behaviour change. Tailored home-based interventions and meaningful clinician recommendations that take into consideration the PA preferences across different groups will help support cancer survivors’ PA behaviour change.
Author contribution
DB, AT, AW, and LT contributed to the conceptualization and design of the study. DB analysed the data and wrote the manuscript, and AT, AW, and LT critically reviewed and revised the manuscript. All authors have read and approved the final manuscript.
Funding
University of Toronto COVID-19 Student Engagement Award.
Data availability
The data used in this study is available on request from the corresponding author, L.T.
Declarations
Ethics approval
This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethics approval was obtained from the University of Toronto’s Research Ethics Board (#00039412).
Consent to participate
Informed consent was completed prior to survey completion.
Competing interests
The authors declare no competing interests.
Conflict of interest
The authors declare no competing interests.
Footnotes
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Brown JC, Huedo-Medina TB, Pescatello LS, Ryan SM, Pescatello SM, Moker E, et al. The efficacy of exercise in reducing depressive symptoms among cancer survivors: a meta-analysis. PLoS ONE. 2012;7(1):e30955. doi: 10.1371/journal.pone.0030955. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Cormie P, Zopf EM, Zhang X, Schmitz KH. The impact of exercise on cancer mortality, recurrence, and treatment-related adverse effects. Epidemiol Rev. 2017;39(1):71–92. doi: 10.1093/epirev/mxx007. [DOI] [PubMed] [Google Scholar]
- 3.Lahart IM, Metsios GS, Nevill AM, Carmichael AR (2018) Physical activity for women with breast cancer after adjuvant therapy. Cochrane Breast Cancer Group, editor. Cochrane Database Syst Rev [Internet]. [cited 2022 Apr 24];2018(1). Available from: http://doi.wiley.com/10.1002/14651858.CD011292.pub2 [DOI] [PMC free article] [PubMed]
- 4.Mishra SI, Scherer RW, Snyder C, Geigle P, Gotay C. The effectiveness of exercise interventions for improving health-related quality of life from diagnosis through active cancer treatment. Oncol Nurs Forum. 2015;42(1):E33–53. doi: 10.1188/15.ONF.E33-E53. [DOI] [PubMed] [Google Scholar]
- 5.Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al. Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc. 2019;51(11):2375–2390. doi: 10.1249/MSS.0000000000002116. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Thraen-Borowski KM, Gennuso KP, Cadmus-Bertram L. Accelerometer-derived physical activity and sedentary time by cancer type in the United States. PLOS ONE. 2017;12(8):e0182554. doi: 10.1371/journal.pone.0182554. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Phillips SM, Dodd KW, Steeves J, McClain J, Alfano CM, McAuley E. Physical activity and sedentary behavior in breast cancer survivors: new insight into activity patterns and potential intervention targets. Gynecol Oncol. 2015;138(2):398–404. doi: 10.1016/j.ygyno.2015.05.026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Smith L, Lee JA, Mun J, Pakpahan R, Imm KR, Izadi S, et al. Levels and patterns of self-reported and objectively-measured free-living physical activity among prostate cancer survivors: a prospective cohort study. Cancer. 2019;125(5):798–806. doi: 10.1002/cncr.31857. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Tannenbaum SL, McClure LA, Asfar T, Sherman RL, LeBlanc WG, Lee DJ. Are cancer survivors physically active? A comparison by US states. J Phys Act Health. 2016;13(2):159–167. doi: 10.1123/jpah.2014-0493. [DOI] [PubMed] [Google Scholar]
- 10.Tarasenko Y, Chen C, Schoenberg N. Self-reported physical activity levels of older cancer survivors: results from the 2014 National Health Interview Survey. J Am Geriatr Soc. 2017;65(2):e39–44. doi: 10.1111/jgs.14589. [DOI] [PubMed] [Google Scholar]
- 11.Tarasenko YN, Miller EA, Chen C, Schoenberg NE. Physical activity levels and counseling by health care providers in cancer survivors. Prev Med. 2017;99:211–217. doi: 10.1016/j.ypmed.2017.01.010. [DOI] [PubMed] [Google Scholar]
- 12.Wong JN, McAuley E, Trinh L. Physical activity programming and counseling preferences among cancer survivors: a systematic review. Int J Behav Nutr Phys Act. 2018;15(1):48. doi: 10.1186/s12966-018-0680-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Clifford BK, Mizrahi D, Sandler CX, Barry BK, Simar D, Wakefield CE, et al. Barriers and facilitators of exercise experienced by cancer survivors: a mixed methods systematic review. Support Care Cancer. 2018;26(3):685–700. doi: 10.1007/s00520-017-3964-5. [DOI] [PubMed] [Google Scholar]
- 14.Hardcastle SJ, Maxwell-Smith C, Kamarova S, Lamb S, Millar L, Cohen PA. Factors influencing non-participation in an exercise program and attitudes towards physical activity amongst cancer survivors. Support Care Cancer. 2018;26(4):1289–1295. doi: 10.1007/s00520-017-3952-9. [DOI] [PubMed] [Google Scholar]
- 15.Hardcastle SJ, Galliott M, Lynch BM, Nguyen NH, Cohen PA, Mohan GR, et al. ‘If i had someone looking over my shoulder…’: exploration of advice received and factors influencing physical activity among non-metropolitan cancer survivors. Int J Behav Med. 2019;26(5):551–561. doi: 10.1007/s12529-019-09808-0. [DOI] [PubMed] [Google Scholar]
- 16.Smith L, Croker H, Fisher A, Williams K, Wardle J, Beeken RJ. Cancer survivors’ attitudes towards and knowledge of physical activity, sources of information, and barriers and facilitators of engagement: a qualitative study. Eur J Cancer Care (Engl) 2017;26(4):e12641. doi: 10.1111/ecc.12641. [DOI] [PubMed] [Google Scholar]
- 17.Smaradottir A, Smith AL, Borgert AJ, Oettel KR. Are we on the same page? Patient and provider perceptions about exercise in cancer care: a focus group study. J Natl Compr Canc Netw. 2017;15(5):588–594. doi: 10.6004/jnccn.2017.0061. [DOI] [PubMed] [Google Scholar]
- 18.Cancer and COVID-19 (novel coronavirus) (2020) In Canadian Cancer Society. Available from: https://cancer.ca/en/living-with-cancer/how-we-can-help/cancer-and-covid19. Accessed 26 Apr 2022
- 19.Faro JM, Mattocks KM, Nagawa CS, Lemon SC, Wang B, Cutrona SL, et al. Physical activity, mental health, and technology preferences to support cancer survivors during the COVID-19 pandemic: cross-sectional study. JMIR Cancer. 2021;7(1):e25317. doi: 10.2196/25317. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Brown M, O’Connor D, Murphy C, McClean M, McMeekin A, Prue G. Impact of COVID-19 on an established physical activity and behaviour change support programme for cancer survivors: an exploratory survey of the Macmillan Move More service for Northern Ireland. Support Care Cancer. 2021;29(10):6135–6143. doi: 10.1007/s00520-021-06165-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Tabaczynski A, Bastas D, Whitehorn A, Trinh L (2022) Changes in physical activity and associations with quality of life among a global sample of cancer survivors during the COVID-19 pandemic. J Cancer Surviv [Internet]. [cited 2022 Aug 16]; Available from: https://link.springer.com/10.1007/s11764-021-01156-x [DOI] [PMC free article] [PubMed]
- 22.Rhodes RE, Liu S, Lithopoulos A, Zhang C, Garcia-Barrera MA. Correlates of perceived physical activity transitions during the COVID-19 pandemic among Canadian adults. Appl Psychol Health Well-Being. 2020;12(4):1157–1182. doi: 10.1111/aphw.12236. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Cantwell M, Walsh D, Furlong B, Moyna N, McCaffrey N, Boran L, et al. Healthcare professionals’ knowledge and practice of physical activity promotion in cancer care: challenges and solutions. Eur J Cancer Care (Engl) 2018;27(2):e12795. doi: 10.1111/ecc.12795. [DOI] [PubMed] [Google Scholar]
- 24.Sallis JF, Johnson MF, Calfas KJ, Caparosa S, Nichols JF. Assessing perceived physical environmental variables that may influence physical activity. Res Q Exerc Sport. 1997;68(4):345–351. doi: 10.1080/02701367.1997.10608015. [DOI] [PubMed] [Google Scholar]
- 25.Yentes R, Wilhelm F (2021) Careless: procedures for computing indices of careless responding. R packages version 1.2.1. Available from: https://cran.r-project.org/package=careless. Accessed 26 Apr 2022
- 26.Curran PG. Methods for the detection of carelessly invalid responses in survey data. J Exp Soc Psychol. 2016;66:4–19. doi: 10.1016/j.jesp.2015.07.006. [DOI] [Google Scholar]
- 27.Meade AW, Craig SB. Identifying careless responses in survey data. Psychol Methods. 2012;17(3):437–455. doi: 10.1037/a0028085. [DOI] [PubMed] [Google Scholar]
- 28.Tabaczynski A, Bastas D, Whitehorn A, Trinh L (2022) Changes in physical activity and associations with quality of life among a global sample of cancer survivors during the COVID-19 pandemic. J Cancer Surviv [Internet]. [cited 2022 Apr 24]; Available from: https://link.springer.com/10.1007/s11764-021-01156-x [DOI] [PMC free article] [PubMed]
- 29.Adams SC, Petrella A, Sabiston CM, Vani MF, Gupta A, Trinh L, et al. Preferences for exercise and physical activity support in adolescent and young adult cancer survivors: a cross-sectional survey. Support Care Cancer. 2021;29(7):4113–4127. doi: 10.1007/s00520-020-05897-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Bauman AE, Reis RS, Sallis JF, Wells JC, Loos RJ, Martin BW. Correlates of physical activity: why are some people physically active and others not? The Lancet. 2012;380(9838):258–271. doi: 10.1016/S0140-6736(12)60735-1. [DOI] [PubMed] [Google Scholar]
- 31.Trost SG, Owen N, Bauman AE, Sallis JF, Brown W. Correlates of adults??? participation in physical activity: review and update. Med Sci Sports Exerc. 2002;34(12):1996–2001. doi: 10.1097/00005768-200212000-00020. [DOI] [PubMed] [Google Scholar]
- 32.Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585–1592. doi: 10.1056/NEJMsr1503323. [DOI] [PubMed] [Google Scholar]
- 33.Hasenoehrl T, Palma S, Crevenna R. Challenges of telemedical exercise management for cancer survivors during the COVID-19 pandemic. Support Care Cancer. 2022;30(12):9701–9702. doi: 10.1007/s00520-022-07055-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Lopez CJ, Edwards B, Langelier DM, Chang EK, Chafranskaia A, Jones JM. Delivering virtual cancer rehabilitation programming during the first 90 days of the COVID-19 pandemic: a multimethod study. Arch Phys Med Rehabil. 2021;102(7):1283–1293. doi: 10.1016/j.apmr.2021.02.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Bland KA, Bigaran A, Campbell KL, Trevaskis M, Zopf EM. Exercising in isolation? The role of telehealth in exercise oncology during the COVID-19 pandemic and beyond. Phys Ther. 2020;100(10):1713–1716. doi: 10.1093/ptj/pzaa141. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Duncan MJ, Spence JC, Mummery WK. Perceived environment and physical activity: a meta-analysis of selected environmental characteristics. Int J Behav Nutr Phys Act. 2005;2(1):11. doi: 10.1186/1479-5868-2-11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Mina DS, Sabiston CM, Au D, Fong AJ, Capozzi LC, Langelier D, et al. Connecting people with cancer to physical activity and exercise programs: a pathway to create accessibility and engagement. Curr Oncol. 2018;25(2):149–162. doi: 10.3747/co.25.3977. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Schmitz KH, Campbell AM, Stuiver MM, Pinto BM, Schwartz AL, Morris GS, et al. Exercise is medicine in oncology: engaging clinicians to help patients move through cancer. CA Cancer J Clin. 2019;69(6):468–484. doi: 10.3322/caac.21579. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Jones LW, Courneya KS, Fairey AS, Mackey JR. Effects of an oncologist’s recommendation to exercise on self-reported exercise behavior in newly diagnosed breast cancer survivors: a single-blind, randomized controlled trial. Ann Behav Med. 2004;28(2):105–113. doi: 10.1207/s15324796abm2802_5. [DOI] [PubMed] [Google Scholar]
- 40.Park JH, Lee J, Oh M, Park H, Chae J, Kim DI, et al. The effect of oncologists’ exercise recommendations on the level of exercise and quality of life in survivors of breast and colorectal cancer: a randomized controlled trial: Exercise Recommendation in Breast Cancer and CRC. Cancer. 2015;121(16):2740–2748. doi: 10.1002/cncr.29400. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Fisher A, Williams K, Beeken R, Wardle J. Recall of physical activity advice was associated with higher levels of physical activity in colorectal cancer patients. BMJ Open. 2015;5(4):e006853–e006853. doi: 10.1136/bmjopen-2014-006853. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used in this study is available on request from the corresponding author, L.T.