Physical activity in advanced urological cancers undergoing immune checkpoint inhibitor treatment: a qualitative study exploring patient perspectives and experiences

Abstract

Purpose

Physical activity (PA) can improve health and treatment outcomes in cancer patients. However, patients with advanced cancer undergoing immune checkpoint inhibitor (ICI) therapy often experience debilitating side-effects that impact PA participation. Because PA experiences in patients with advanced cancer undergoing ICI therapy are not well known, in this study we aimed to explore their perceptions and lived experiences.

Method

Twelve adults with advanced urological (bladder or renal) cancer undergoing ICI therapy at a tertiary cancer centre, London, UK, participated in individual semi-structured qualitative interviews. A topic guide facilitated discussions. Interviews were audio-recorded and transcribed verbatim. Data was inductively analysed following Braun and Clarke’s six-phases of Thematic Analysis.

Results

In-person interviews lasting 34–69 min revealed four main themes: 1) Purpose of PA participation, 2) Factors influencing PA participation (facilitators/barriers), 3) Limited ameliorative support from healthcare professionals, and 4) Desired PA support. Overall, participants reported suboptimal PA levels attributed to inadequate PA knowledge and cancer/ICI treatment-related side-effects such as fatigue and pain. PA facilitators included self-motivation, positive valance, and healthcare professionals support regarding PA benefits and safety.

Conclusions

Structured PA is a promising strategy for managing cancer and treatment-related side-effects during ICI therapy; however, findings from this study indicate that it is underutilised. Patients undergoing ICI therapy have distinct PA needs, necessitating personalised support. Integrating PA interventions, such as PA counselling and timely referrals to cancer exercise/rehabilitation specialists into cancer care pathways, is essential. Further research should explore optimal strategies to enhance PA participation and maximise its benefits during ICI treatment.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1007/s00520-026-11195-8.

Introduction

Bladder and renal cancers are the second and third most common urological malignancies worldwide, with over 614,000 and 434,840 new cases diagnosed annually, respectively [1]. Until recently, survival rates for advanced bladder or renal cancer were low [2]. However, the emergence of immunotherapy agents such as immune check-point inhibitors (ICIs), which target CTLA-4, PD-1, and PD-L1 to enhance immune-mediated tumour cell death, has significantly improved long-term survival outcomes in patients with advanced urological cancers [3].

While ICIs offer survival benefits, they also cause a range of treatment-related toxicities affecting multiple organ systems, including the skin, gastrointestinal, endocrine, respiratory, and musculoskeletal systems [4, 5]. In line with this, many patients experience high treatment burden due to associated ICI-related side-effects such as fatigue, weakness, joint pain and muscle pain [6]. These symptoms can be debilitating, significantly impacting daily activities, such as walking and work, and leading to a reduced health-related quality of life (HRQoL) [7, 8]. In cases of severe toxicities this may necessitate dose modification or treatment discontinuation [6]. Therefore, supportive interventions are required to mitigate side-effects while maximising treatment efficacy.

Physical activity (PA) (henceforth used synonymously with exercise)1 [9] can mitigate for cancer treatment-related side-effects such as fatigue and anxiety [10, 11]. Exercise has also been associated with improved treatment-related outcomes, physical function and HRQoL outcomes across cancer populations [10–12], with emerging evidence supporting its integration within immunotherapy treatment pathways [13]

Notably, integrating exercise with cancer treatments may exert immunomodulatory effects that contribute to tumour control [14]. In preclinical research, moderate-intensity exercise has been found to reduce tumour size by boosting immune responses, particularly through the mobilisation of highly differentiated natural killer cells and increased intratumoral CD8 + T cell infiltration [14, 15]. This suggests that exercise may have both a ‘conditioning’ and ‘tumour immune surveillance’ effect [16].

Current guidelines recommend that adults with cancer engage in at least 150 min of moderate-intensity or 75 min of vigorous-intensity aerobic exercise per week, along with two sessions of resistance-based exercise [17]. However, PA levels often decline following a cancer diagnosis, with fewer than 30% of individuals meeting exercise recommendation [18, 19]. Despite strong evidence supporting its benefits, PA interventions remain underutilised and are not routinely integrated into cancer care pathways [20, 21]. To date, few empirical studies have investigated PA in the context of cancer immunotherapy, and to our knowledge, no published work has explored PA perceptions or experiences among patients undergoing ICI therapy. To effectively integrate PA into cancer care, it is important to understand how patients perceive and engage with it during ICI therapy. This study explores the experiences of urological cancer patients undergoing ICI treatment at a tertiary NHS cancer centre, specifically examining; the perceived benefits of PA, and the barriers, facilitators and preferences related to PA engagement. The findings aim to inform the design of future PA interventions tailored to the needs of this patient population.

Methods

Study design

Using a qualitative approach, individual semi-structured interviews were conducted to explore the perceptions and lived experiences of PA among cancer patients undergoing ICI therapy. Grounded in the philosophy of interpretive phenomenology, the study adopted a relativist/constructivist paradigm, which acknowledges individuals’ interpretations of their experiences and recognises the researcher’s role in constructing data insights [22]. To provide a clear and structured framework for data analysis, Braun and Clarks (2006) Thematic Analysis (TA) was employed [23]. The study obtained ethical approval from the Health Research Authority and East Midlands Research Ethics Committees (REC: 24/EM/0019, IRAS ID: 333,272), and adhered to the World Medical Association Declaration of Helsinki (2013) [24]. All participants provided written informed consent prior to interview. Reporting is in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Online-resource-1) [25].

Participant recruitment

A purposive sampling strategy was used to recruit twelve adults (7 males, 5 females) with advanced bladder or renal cancer undergoing ICI therapy at a tertiary cancer centre in London, UK. Participants were recruited to reflect variation in gender, disease duration, and age to capture a broad range of experiences relevant to the research question. Eligible participants were aged ≥ 18 years, with histologically confirmed bladder or renal cancer currently receiving ICI therapy. Exclusion criteria included those with a prognosis of less than six months and non-English speakers. Recruitment materials including participant information leaflets were distributed during outpatient oncology appointments, with interested individuals contacting the research team for further information, screening and scheduling. No relationship existed between participants and the interviewer prior to recruitment. Participants were informed that the interviewer was a clinical researcher and that the study aimed to explore experiences of physical activity during immunotherapy. A sample of twelve was deemed sufficient to support in-depth and rich analysis, consistent with the principles of TA and in line with idiographic qualitative research [23, 26].

Data collection

Data collection involved semi-structured interviews, structured by a topic guide [27] informed by relevant literature and the Health Belief Model (HBM) [28], exploring perceived benefits, barriers, self-efficacy and behavioural influences on physical activity participation. The HBM was selected as it provides a theoretical framework for understanding factors influencing engagement in health behaviours, including physical activity. The guide was reviewed by the study team and piloted in two practice interviews before formal data collection. Although interviews followed a structured format, open-ended questions (Online-resource-2) allowed for an in-depth exploration of participants’ experiences of PA. The main interview questions were structured into four categories: PA experiences, perceived benefits, barriers and facilitators to PA participation, and preferences for PA support and interventions (Table 1).

Table 1.

Example of topic guide – key areas of exploration and interview questions derived from the literature

Area of exploration All participants were provided with a definition for PA and exercise at interview	Example questions
Levels of PA and/or exercise activity	Can you tell me about your experiences of PA/exercise?
Experiences of PA and/or exercise when receiving ICI treatment	Can you tell me about your experiences of PA/exercise since your diagnosis and receiving ICI treatment?
Barriers to partaking in PA and/or exercise	Can you describe your experiences of the challenges you have had partaking in PA/exercise?
Facilitators and motivators to partaking in PA and/or exercise	Can you describe your experiences of the things that have facilitated – helped partaking in PA/exercise?
Preferences and Support needs for PA and/or exercise	Can you tell me about the types of PA/exercise you would prefer to partake in during ICI treatment?

Interviews took place at the hospital and at a time convenient for participants. The lead researcher (NP, female), with 15 years’ experience in cancer rehabilitation, facilitated the interviews, which lasted a median of 41 min (range 34–69 min). Interviews were audio-recorded, transcribed verbatim, and member-checked for data accuracy. Member-checking was conducted by sharing transcripts with participants for feedback, though no modifications were required. Prior to the interview, participants also completed a demographic survey and self-reported PA questionnaire (International Physical Activity-Questionnaire) [29]. To ensure confidentiality, all data were pseudonymised with a study number identifier assigned to each participant.

Data analysis

Data was analysed inductively using Braun and Clarke’s (2022) six-phase approach to TA, supported by NVivo-13 software [30]. The lead researcher (NP) led the analyses, beginning with immersion in the data through repeated reading of all transcripts. Initial codes were generated systematically across the dataset using line-by-line coding to identify key features related to participants’ experiences of PA during ICI therapy. A second researcher (IV) independently read a subset of transcripts and noted initial impressions to support reflexive discussion and enrich the interpretive process. This collaborative engagement aimed to enhance analytical depth and transparency in line with the principles of TA. To avoid premature categorisation, codes were then reviewed, organised into sub-themes, and subsequently grouped into broad themes through an iterative and interpretive process. Throughout, attention was paid to both shared and divergent experiences to provide a nuanced understanding of the data. Themes were further refined through wider research team discussions, which facilitated critical engagement with the data and supported a nuanced understanding.

A reflexive diary and audit log were maintained to document analytical decisions and support transparency. Findings were heavily grounded in participant’s accounts, and informed the development of the study’s recommendations. All characteristic data (demographic and clinical) are presented descriptively.

Findings

Participant demographics and clinical characteristics are described in Table 2.

Table 2.

Interview participants: characteristics of patients with advanced bladder (n = 5) or renal (n = 7) cancer

Characteristic	Total study cohort (n = 12) Mean (SD) or n (%)
Age (years)	61 (11.3)
Time since cancer diagnosis (months)	20 (13.6)
Gender
Male Female	7 (58%) 5 (42%)
Ethnicity
White/British White/Black Caribbean Black/British African Indian	8 (67%) 1 (8%) 1 (8%) 2 (17%)
IMD
1 to 5—Most deprived 6 to 10—Least deprived	5 (42%) 7 (58%)
Civil status
Married or lives with partner Divorced/separated	9 (75%) 3 (25%)
Occupation
Retired Working/part working Not working	4 (33%) 6 (50%) 2 (17%)
Metastatic Site(s)
One  > two	7 (58%) 5 (42%)
ICI treatment
Time on ICI treatment (months) ICI regimen	8.1 (13.7)
Ipilimumab/Nivolumab Durvalumab Atezoluzimab Avelumab/Axitinib Nivolumab	6 (50%) 1 (8%) 3 (25%) 1 (8%) 1 (8%)
Other treatment to primary or distant metastases
Surgery Chemotherapy Radiotherapy None	11 (92%) 2 (17%) 1 (8%) 1 (8%)
*Meeting physical activity guidelines (IPAQ)
Yes No	2 (17%) 10 (83%)
**Decline in physical activity levels since diagnosis
Yes No (No change)	9 (75%) 4 (33%)

^*Meeting physical activity guidelines were determined from IPAQ responses

^**Decline in physical activity levels since diagnosis were determined from participants experience responses

IMD, Index of multiple deprivation – measures deprivation (Gov.UK, 2023); SD, Standard deviation; ICI, Immune checkpoint Inhibitor; IPAQ, International Physical Activity Questionnaire

Following thematic analysis of the dataset, four main themes emerged with eight related sub-themes (Table 3). Each theme is described in the subsequent sections, alongside direct participant quotations.

Table 3.

Main thematic domains and their related sub-themes generated from the coded dataset

Main Theme	Sub-theme: ‘Experience and perception of Physical activity…’
1. Purpose of PA participation	Enablers to independence & participation in daily activities
	Role of hope when living in uncertainty
2. Factors influencing PA participation	Facilitators
	Barriers
3. Limited ameliorative support from HCPs	Vague, lack of advice received
	Appetite for more information
4. Desired PA support – What is wanted	Personalised support
	Goal-tracking target

Theme 1: purpose of PA participation

Participants described the emotional impact of having a diagnosis of cancer, highlighting the uncertainty, and treatment burden it imposed. A strong convergence emerged regarding the need for purpose, with PA playing a key role in maintaining daily activities, normalcy and enabling independence during treatment.

"It’s about being able to live your life the way you want to, and about being independent." (PA01)

"I don’t want to get to the stage that I can’t do anything for myself…I want to keep as much independence as I can to enjoy my family and life." (PA08)

Rather than structured exercise, most participants discussed engaging in activities, such as walking, with it providing a sense of purpose and motivation within their daily routines.

"I walk to work because I like it, it’s how I make sure I do something and it keeps me active." (PA02)

"I go for 20-30-minute walks most days… it’s important to help my wife with the shopping, play with my grandchildren, and stay mobile. My walks help me to stay fit to do these things." (PA04)

Furthermore, ICI therapy was widely viewed as a ‘beacon of hope’, motivating participants to stay active in pursuit of optimal treatment outcomes.

"This treatment is my last hope of survival…I’ve really got to do everything I can to be fit and well to have it." (PA03)

Theme 2: factors influencing PA participation

Participants identified a range of facilitators and barriers that influenced their ability to engage in PA during ICI treatment. Most emphasised the health benefits of PA, citing its role in “maintaining fitness” (PA03), “improving mood” (PA07), and managing comorbid conditions such as “diabetes” (PA04).

"I’m also pre-diabetic, so I needed to do something about it... I exercised to lose some weight and reduce the risk." (PA04)

Participants also described how PA helped alleviate cancer-related symptoms and treatment side-effects, such as fatigue, weakness, weight changes, and pain.

"My fatigue levels and pain in my right hip were really bad…Then, I saw the lady (Physio instructor) in the cancer centre gym... I now walk at a good pace on the treadmill and take my grandkids to the park." (PA01)

Intrinsic motivators, such as self-determination and the desire to resume normal activities, like gardening, shopping or work, emerged as prominent facilitators of PA.

"I love doing gardening because it gets me fresh air, and it’s hard work for me. Then, of course, I get the pleasure of sitting outside, admiring my work… The garden gives me a focus." (PA08)

PA also provided a sense of self-control, routine and sanctuary. Some participants referred to PA as their "therapy place"(PA10), enhancing well-being and providing a “happiness factor”.

Despite these facilitators, several barriers impeded PA engagement. The most common including lack of knowledge about PA benefits, dislike of structured exercise, and side-effects from the cancer or treatment.

Specifically, fatigue was a major challenge: significantly impacting daily function and PA engagement.

"I had absolutely no energy… difficult when you're feeling fatigued to think about doing exercise." (PA11)

For many, fatigue and lack of energy was associated with treatment-induced cortisol dysfunction and hypothyroidism.

"My pituitary gland has been attacked since being on the treatment... I couldn’t walk to the end of the road and had to ask to work from home. I said to my oncologist, ‘I’m more knackered now than when I was in the army." (PA03)

Pain from the primary cancer site or metastatic disease also hindered PA uptake.

"I have two areas in my leg that the cancer has travelled to… It is that pain I get in my hip and leg from the cancer that really stops me a lot from doing it [Physical activity]." (PA10)

Furthermore, other treatment side-effects, such as weakness, nausea/vomiting, and skin rash/itchiness, further limited engagement.

Psychological factors, played a role, with some participants reporting low motivation or mood affecting their ability to engage in PA. One participant described being in a “dark period” (PA11), highlighting the emotional toll of cancer and its treatment.

"The cancer hit me hard, and I found myself in a really dark place. Other than coming to my appointments, I would spend most of my time in bed with the blanket over my head... If I had seen someone to help me snap out of it, things might have been different." (PA11)

Before diagnosis, most participants led active lives. However, their physical capabilities declined post-diagnosis, reducing their participation in previously enjoyed activities, like walking, running, and cycling. Hospital commitments and uncertainty about the impact of PA’s effects on their cancer further contributed to this decline.

"I just stopped doing things like going for walks, doing the school run… mainly because I didn’t think I could do it. It might be the pain one day, fatigue the next… I didn’t know what I could or couldn’t do or how to help it." (PA05)

Social support varied, playing a dual role acting both as a facilitator and a barrier. While some participants received encouragement from family and friends to be active “They encourage me…liked to see me up and about and would organise park walks or walks to the shop” (PA04). Others, reported discouragement due to family concerns about safety, leading them to reduce PA engagement. "They didn’t want me to help around the home or go to the gym, so I cancelled my gym subscription" (PA06).

Theme 3: limited ameliorative support from healthcare professionals

Overwhelmingly, all participants reported receiving little to no PA advice from healthcare professionals (HCPs) during routine medical appointments. Some recalled vague guidance, like "keep doing what you are doing" (PA08), while the majority received none: "No! No one spoke to me about anything to do with being active or doing exercise" (PA01).

When asked if receiving PA advice would have been helpful, all but one participant affirmed its value.

"If I had the information about doing exercise, it totally would have changed the way I feel about it." (PA03)

Some participants reported that reading the study’s information sheet influenced their interest to engage in PA and increased their desire to seek out further support.

"There is a lot that we can’t control when on the treatment, but I could have done some exercise if I knew what I know now from reading the study information sheet… This information should really be given to us at the start." (PA12)

Beyond highlighting a lack of advice, these accounts demonstrated participants’ desire for trustworthy information, with many perceiving that earlier guidance and support may have increased their confidence and willingness to engage in physical activity during treatment.

Interestingly, participants perceived clinical staff as prioritising pharmacological management of treatment side-effects over discussing the PA role in it. While a few were referred to physiotherapy, these referrals were primarily for managing impairments and disability, rather than for PA for its broader benefits.

There was strong consensus on the importance of receiving reliable PA advice early in treatment. Over half the participants expressed HCPs, family, and caregivers should share responsibility for providing PA support. However, most preferred receiving initial permission to engage in PA from doctors.

"It would be better coming from my oncologist first, because they are the ones you listen to the most and get the clearance from… I am not sure I would do it otherwise." (PA07)

Theme 4: PA support – what is wanted

Participants emphasised the need for structured, personalised PA guidance over vague advice or generic leaflets.

"Often you just don’t know where to start. I need support in knowing what to do and how to do it… not just do more exercise or get handed a leaflet… I need somebody to give me and show me how to do the right exercises for me and include ones I can do for the cancer in my hip." (PA12)

Moreover, safety concerns, particularly fracture risk, were common with participants reinforcing the need for trusted expert-led support.

"Seeing the trained physio at the centre is where I have trust, I know they will consider all my needs…They have knowledge about cancer, how to exercise and know about me, like the cancer is in my back and leg." (PA01)

Clear targets, and progress tracking were seen as key motivators.

"I’m extremely competitive, so if someone said, I am going to check your exercise record and every week you’ve got to do 70,000 steps, I’ll do 70,000 steps." (PA03)

Participants preferred flexible PA options, including, hospital-based (n = 9), home-based (n = 9), gym-based (n = 5) or local venue (n = 4), provided they had expert-led oversight. Walking (n = 10) and strength training (n = 8) were the most favoured PA modes, followed by cycling (n = 5) and swimming (n = 4).

However, all participants emphasised the importance of a flexible PA programme integrated into routine care to accommodate symptom fluctuations and thus advocating for periodised (auto-regulated) approaches.

"The treatment means I have good and bad days, so integrating exercises into my day and during my treatment cycles is important… On a treatment week I might need to do less depending on how I feel but on the weeks after treatment I could do more… Doing some exercises at home and at the cancer centre would be best." (PA11)

Discussion

This study is the first to explore the perceptions and experiences of PA in cancer patients undergoing ICI therapy. In line with previous research [18, 19], most participants experienced a decline in PA following diagnosis. Contributing factors included frequent hospital visits, treatment side-effects, and lack of PA knowledge or support. HCPs are recognised as influential in promoting PA among cancer patients [31]; but consistent with prior findings [20, 21], this study indicates that structured PA discussions rarely occur within cancer care pathways. Overwhelmingly, none of our study participants reported receiving structured PA guidance in their medical consultations, and only a quarter recalled having general PA conversations. This aligns with the broader evidence suggesting that between 6–44% of cancer patients receive PA information during oncology appointments [32, 33].

PA interventions such as structured exercise should be presented to patients as a key component of their cancer care, with benefits outweighing perceived effort or inconvenience. The disconnect between patients’ interest in PA and the lack of advice in our findings highlights a missed opportunity to harness teachable moments during treatment. Potential reasons for this gap may reflect limited knowledge, confidence and time among medical and nursing professionals to deliver PA advice, alongside the common prioritisation of treatment readiness and its pharmacological management in consultations [11, 34]. Embedding professionals with cancer-specific exercise expertise, such as physiotherapists, directly into cancer clinics and pathways may address this more effectively, offering sustainable, evidence-based support to addressing PA needs without overburdening existing medical appointments. This model has shown promise in improving referral pathways and patient engagement in PA [35]. Given PA’s potential in enhancing immunotherapy response and QoL [36, 37], embedding formalised PA interventions within cancer pathways is a critical next step.

The importance of recognising both barriers and facilitators to the PA experience should not be overlooked. Our findings align with existing studies [38] where cancer-related health factors such as fatigue and metastatic disease-related pain were frequent physical barriers. However, a novel finding in this study was the identification of barriers unique to ICI therapy, such as cyclical endocrine-related fatigue, nausea, vomiting, and skin itchiness. These symptoms fluctuated across treatment cycles, presenting additional and unique challenges to PA engagement and exercise prescription.

Although PA can countermeasure treatment related side-effects [17], the challenges faced by patients during treatment may require approaches that include flexible, periodisation constructs. In this regard, our findings support research by Kirkham et al. 2019 [39], which showed that periodised exercise interventions tailored to treatment cycles result in better adherence to exercise and symptom management compared to linear progression interventions. This suggests that PA interventions during active treatment should be flexible to accommodate symptom variability.

Barriers such as low confidence, limited PA knowledge, and concerns about PA worsening cancer pathology were also reported. Consistent with Sheill et al., 2019 [38], participants preferred receiving supervised PA prescription and support from specialist services and HCPs such as physiotherapists with exercise oncology expertise. These professionals were perceived as providing realistic, relevant exercise guidance (bone health, pain, fatigue, cancer treatment), reinforcing the need for expert-led, patient-centred PA interventions. However, access to these services are often referral-based rather than being embedded within the frontline treatment pathway, restricting early support [35, 40]. Despite these barriers, our data overwhelmingly indicates a positive valence for PA, with participants associating it with emotions such as hope, enjoyment, normalcy and independence. This aligns with illness representation theories [41], which posits that patients seek ways to regain control and well-being amid diagnosis and treatment uncertainty.

Interestingly, unlike previous studies [42], socioeconomic or environmental factors such as financial constraints, transportation or availability of PA facilities were not major barriers to PA engagement in our study. This may reflect the supportive context of the specialist unit ICI therapies are delivered in, and the convenient transport infrastructure at the site this study was conducted in, which may have led to an under-reporting of these factors. Nevertheless, our study participants strongly favoured hybrid PA models, combining supervised sessions with home-based activities, structured around clear goals, and progress monitoring. Furthermore, walking, resistance training, swimming, and cycling were among the most preferred forms of PA, echoing existing literature [42].

Limitations

Findings from our study should be interpreted considering its limitations. While a purposeful sample was used, recruitment from a single UK tertiary centre with a homogenous cancer group limits generalisability to broader cancer populations and transferability to other clinical settings. Additionally, the cohort solely included patients receiving ICIs, potentially limiting applicability to other treatments such as chemotherapy or targeted therapies. However, the study sample is reflective of patients with urological cancers [43] and the rigorous methodology ensures applicability of the findings to similar clinical contexts, with potential replication in future research.

Recommendations

This study, highlights the importance of integrating structured PA into cancer care for individuals undergoing immunotherapy. To address the current gaps in care, we recommend the development and implementation of PA interventions that are accessible, scalable, and responsive to the specific needs of this patient group. Firstly, future research is recommended to enhance care coordination and referral pathways to ensures timely access to HCPs with cancer rehabilitation and exercise expertise. Secondly, investigating HCPs’ education and skill gaps regarding PA could inform targeted training initiatives across multidisciplinary teams. Finally, future studies should: a) evaluate PA interventions across different patient groups undergoing cancer treatment and establish the needs and benefits of structured PA support tailored to the needs of these groups; b) explore which ICI-related side-effects can be mitigated through PA, and assess the acceptability and efficacy of different intervention formats to enhance long-term engagement.

Conclusion

PA represents a promising and transformative strategy for managing cancer and its treatment-related side-effects during ICI therapy, yet it is underutilised. Our findings suggest that patients undergoing ICI therapy have distinct PA support needs, necessitating tailored interventions that accommodate their cancer-specific and treatment related challenges. To address this, timely referrals to trained HCPs in cancer rehabilitation and exercise, and structured PA counselling integrated into routine cancer pathways may improve not only symptom management and patient outcomes, but also treatment tolerance, autonomy, hope, and resilience. Future research should prioritise the development of accessible, scalable PA interventions to promote PA adoption and maximise the therapeutic benefits of PA in this population.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contribution

Conceptualisation: Nicola Peat, Mieke Van Hemelrijck, Gareth Jones. Methodology: Nicola Peat, Mieke Van Hemelrijck, Gareth Jones, Netty Kinsella. Investigation: Nicola Peat, Mieke Van Hemelrijck, Gareth Jones, Netty Kinsella. Formal analysis: Nicola Peat, Isla Veal, Mieke Van Hemelrijck, Gareth Jones. Writing—original draft preparation: Nicola Peat. Writing—review and editing: Nicola Peat, Mieke Van Hemelrijck, Gareth Jones, Isla Veal, Netty Kinsella, Sophia Karagiannis. Supervision: Mieke Van Hemelrijck, Gareth Jones, Netty Kinsella.

Funding

The lead researcher (NP) conducted this study as part of a master’s in clinical research funded by the NIHR Pre-doctoral fellowship award (NIHR301975). The views expressed are those of the author(s) and not of the NIHR.

Data availability

Anonymised data utilised for the analysis of this study will be available with reasonable requests to the corresponding author.

Declarations

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Prospective approval was granted by an NHS Research Ethics Committee (REC: 24/EM/0019) and the Health Research Authority (IRAS ID: 333272).

Consent to participate

Written informed consent was obtained from all individual participants included in the study.

Consent for publication

Patients signed a written informed consent form regarding publishing their non-identifiable data, including quotes in this article.

Competing interests

The authors declare no competing interests.