Physical Activity

Abstract

BACKGROUND:

As treatments improve for colorectal cancer (CRC), interventions to improve quality of life and decrease long-term effects are needed. Physical activity (PA) is particularly important during cancer treatment because it may decrease treatment side effects, allow patients to more easily increase PA after treatment, and integrate with individuals’ motivation to make lifestyle changes after a cancer diagnosis.

OBJECTIVES:

This article aims to synthesize what is known about PA during CRC treatment.

METHODS:

A systematic literature search was conducted. Data were evaluated across 17 studies with a collective sample size of 1,184. Because of heterogeneity across studies, a narrative synthesis was conducted.

FINDINGS:

Studies included mostly college educated and married White men and women aged 50–60 years. Promising effects of PA were identified on several types of outcomes. The most common techniques to support PA included goal setting and providing instructions. The benefits of PA and how to best support PA during CRC treatment need to be better understood in future studies of racially and ethnically diverse patients with CRC.

colorectal cancer (crc) is the third most common cancer in the world (American Cancer Society [ACS], 2021). Because of increasing survival rates, there is a need improve survivors’ quality of life (QOL), physical functioning, recurrence risk, and comorbidity prevalence (ACS, 2020). Many patients with CRC have poor QOL during and after treatment; other common side effects include fatigue, depression, anxiety, and decreased sleep quality (Bourke et al., 2014; Cramer et al., 2014; Gao et al., 2020). Focusing on the treatment period is important because physical activity (PA) may decrease side effects and prevent PA decline and functional decline, both of which can become significant barriers to PA following treatment. In addition, patients with CRC have a higher rate of comorbidities than patients without cancer, making lifestyle changes pre- and post-treatment particularly important for their continued survival and QOL (ACS, 2020).

PA improves the QOL, fatigue, anxiety, depression, and sleep of patients with CRC and is also associated with decreased recurrence and increased survival (Balhareth et al., 2019; Gao et al., 2020; Turner et al., 2018). Among survivors who were physically active prior to diagnosis, PA levels tend to drop during treatment and do not return after treatment’s completion (Hirschey, Nyrop, & Mayer, 2020; National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, 2017). Because maintaining PA is proven to be beneficial, the American College of Sports Medicine Roundtable Report on Physical Activity, Sedentary Behavior, and Cancer Prevention and Control includes updated PA recommendations for all individuals living with cancer to engage in moderate-intensity aerobic exercise for 30 minutes at least three times per week for at least 8–12 weeks and to add resistance/strength training at least two times per week, with a minimum of two sets of 8–15 repetitions at 60% of one repetition maximum (Campbell et al., 2019). Despite these recommendations and research demonstrating that PA interventions are safe, effective, and feasible for patients with CRC, it is estimated that only about 24% of patients with CRC are physically active and follow PA guidelines during and after treatment (Bourke et al., 2014; Turner et al., 2018). The purpose of this article is to synthesize what is known about PA so that nurses may make informed recommendations to promote PA during chemotherapy treatment for CRC.

Methods

This review follows PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and is registered with Prospero. A medical librarian conducted a systematic literature search. Oncology clinical nurses and nurse and behavioral scientists with expertise in exercise oncology research synthesized and interpreted findings.

Literature Search

Systematic literature searches were conducted on October 8, 2019, using MEDLINE^® via PubMed^®, Web of Science, Embase^®, SPORTDiscuss, PsycINFO^®, and CINAHL^®. No date restrictions were applied. Results were limited to English-language articles. The reference lists of studies identified were manually searched for additional relevant citations to avoid retrieval bias. Inclusion criteria consisted of (a) having a study sample of participants with a colon or rectal cancer diagnosis who were undergoing chemotherapy or radiation therapy; (b) testing a PA intervention; and (c) reporting primary, secondary, or exploratory behavioral, psychosocial, and/or physiologic outcomes. Randomized controlled trials (RCTs), non-RCTs, and single-group pre-/post-test designs were included. Studies involving participants with different types of cancer were included only if results were reported separately for participants with CRC. All modes and intensities of PA were included. Both supervised and home-based interventions were included. Mindfulness interventions were excluded.

Initial searches yielded 1,872 titles and abstracts for consideration. After removing duplicates, 1,543 titles and abstracts were independently reviewed for eligibility by two team members. If an abstract lacked detail to determine eligibility, the full-text article was retrieved. The full text of 151 articles was independently reviewed by two team members to confirm whether each met inclusion criteria. Seventeen studies, with a collective sample size of 1,184, are included in this review (see Figure 1).

FIGURE 1. PRISMA FLOW DIAGRAM.

PRISMA—Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Literature Synthesis

Two researchers independently extracted data from included studies into a customized Cochrane data collection form and assessed the methodologic quality of each article using the Cochrane risk of bias assessment tool. Disagreements between researchers were resolved though discussion and/or consultation with a third researcher. The matrix method (Garrard, 2013) was applied to write a narrative synthesis of what is known about PA interventions for CRC survivors undergoing treatment.

Findings

Details of included studies are outlined in Table 1. Sample sizes ranged from 10 to 410, and studies were conducted in 12 countries. Nine studies were RCTs, two were non-RCTs, and six were single-group pre-/post-test designs. Across studies, men and women who were educated, married, aged 50–60 years, and had a body mass index above what is considered healthy (i.e., 25) were included. Of the two studies that reported race and ethnicity, most participants were reported as White.

TABLE 1.

PHYSICAL ACTIVITY AND PATIENTS WITH COLORECTAL CANCER: SELECTED STUDIES (N = 17)

STUDY AND COUNTRY	DESIGN AND SAMPLE
Colon cancer
Van Vulpen et al., 2016 (Netherlands)	RCT; N = 33; mean age of 58 years (SD = 10); 64% male and 36% female; mean BMI of 26 (SD = 4); 100% undergoing CT; 9% undergoing RT
van Waart et al., 2018 (Netherlands)	RCT; N = 23; mean age of 58 years (SD = 10); 39% male and 61% female; mean BMI of 24 (SD = 3); 100% undergoing CT; 4% undergoing RT
Zimmer et al., 2018 (Germany)	RCT; N = 30; mean age of 69 years; 30% male and 70% female; mean BMI of 24; 100% undergoing CT
Colorectal cancer
Backman et al., 2014 (Sweden)	RCT; N = 17 patients with CRCa; mean age of 54 years; 10% male and 90% female; mean BMI of 25 (SD = 4); 100% undergoing CT
Cheong et al., 2018 (South Korea)	Single-group intervention; N = 102; mean age of 58 years (SD = 12); 59% male and 41% female; mean BMI of 24 (SD = 1); 100% undergoing CT
Hawkes et al., 2009 (Australia)	Single-group intervention; N = 20; 50% male and 50% female; 35% undergoing CT; 20% undergoing RT
Hawkes et al., 2014 (Australia)	RCT; N = 410; mean age of 66 years (SD = 10); 54% male and 46% female; mean BMI of 25 (SD = 5); 24% undergoing CT; 1% undergoing RT
Heislein & Bonanno, 2009 (United States)	Single-group intervention; N = 12; mean age of 61 years (SD = 11); 34% male and 66% female; 100% undergoing CT
Li & Liu, 2019 (China)	RCT; N = 298; mean age of 59 years (SD = 12); 64% male and 37% female; 100% undergoing CT
Lin et al., 2014 (China)	Two-group non-RCT; N = 45; mean age of 57 years (SD = 10); 58% male and 42% female; mean BMI of 23 (SD = 3); 100% undergoing CT
Lu et al., 2019 (China)	RCT; N = 90; mean age of 55 years (SD = 12); 64% male and 36% female; 100% undergoing CT
Møller et al., 2015 (Denmark)	RCT; N = 12 patients with CRCa; mean age of 51 years (SD = 10); 89% male and 11% female; mean BMI of 25 (SD = 4); 100% undergoing CT
Sohl et al., 2016 (United States)	RCT; N = 15; 60% male and 40% female; 80% White and 20% Black; 100% undergoing CT
Rectal cancer
Alejo et al., 2019 (Spain)	Single-group intervention; N = 10; mean age of 61 years (SD = 7); 25% male and 75% female; mean BMI of 29 (SD = 4); 100% undergoing CT and RT
Loughney et al., 2017 (United Kingdom)	Two-group non-RCT; N = 39; mean age of 68 years; 73% male and 28% female; 100% undergoing CT and RT
Morielli et al., 2016 (Canada)	Single-group intervention; N = 18; mean age of 58 years (SD = 10); 67% male and 33% female; 94% White and 6% Asian; mean BMI of 29 (SD = 4); 100% undergoing CT
Singh et al., 2018 (Australia)	Single-group intervention; N = 10; mean age of 55 years (SD = 14); 70% male and 30% female; mean BMI of 26 (SD = 3); 100% undergoing CT and RT

^aThe total sample size was larger.

BMI—body mass index; CT—chemotherapy; RCT—randomized controlled trial; RT—radiation therapy

Increasing Physical Activity

Across studies, moderate- and/or vigorous-intensity PA is the most frequently evaluated; many types of PA have been tested during CRC treatment, including combination strength and aerobic programs, walking, yoga, stationary cycling, aerobic activity of choice, gym aerobic machines, and traditional Chinese medicine exercises. In some studies, PA increased (Alejo et al., 2019; Cheong et al., 2018; Lin et al., 2014; van Waart et al., 2018); in others, it decreased (Backman et al., 2014; Hawkes et al., 2009; Loughney et al., 2017). However, in studies where PA decreased, there were not control groups. In addition, sedentary behavior improved in two studies (Alejo et al., 2019; Hawkes et al., 2009). Taken together, these findings indicate that patients with CRC may be able to increase their activity levels during chemotherapy; when levels of activity do decline, they may decline less than they would have without a PA intervention. Table 2 provides a summary of PA in each included study, how interventions were delivered, and study designs and outcomes. Generally, PA was acceptable among patients: 72%–100% of participants were satisfied with PA interventions (Hawkes et al., 2009, 2014; Sohl et al., 2016); 72% of patients reported that a PA program helped them deal with problems more effectively; and 100% of participants said they would recommend the program (Hawkes et al., 2009, 2014). Although largely positive experiences with PA interventions were reported across studies, reasons patients did not want to engage in PA were also identified. These included too many things on the patient’s mind, no desire to exercise alone, poor timing, travel distance, exercise being too time-consuming, and not wanting to exercise.

TABLE 2.

DESCRIPTIONS AND OUTCOMES OF SELECTED STUDIES (N = 17)

STUDY	PA INTERVENTION	OUTCOMES
Non–randomized controlled trials
Lin et al., 2014	Progressive aerobic and resistance program involving resistance exercises and ergometer; moderate-intensity supervised (physical therapist) PA 2 days per week for 40–60 minutes each, with encouragement to engage in PA independently on additional days	Positive change in QOL, fitness, muscle strength, and PAa; no change in distress, fatigue, and sleep
Loughney et al., 2017	Individualized in-hospital program involving stationary bike; moderate- and vigorous-intensity supervised PA 3 times per week for 40 minutes each	Positive change in sleepa; negative change in PA
Randomized controlled trials
Backman et al., 2014	Goal of 10,000 daily steps and 1 weekly 1-hour supervised group walk; supervised PA; also included unsupervised PA	Positive change in QOL; negative change in PA
Hawkes et al., 2014	11 telephone health coaching sessions aimed at encouraging goal of 10,000 daily steps; unsupervised PA	Positive change in QOLa, distress, post-traumatic growtha, spiritualitya, acceptancea, and mindfulness
Li & Liu, 2019	Health education, telephone counseling, and supervised progressive multimodal PA involving restorative, resistance, and aerobic exercise; low-, moderate-, and vigorous-intensity supervised (specialist nurse) PA once a week for 90 minutes for the first 3 months, then 3 times per week for 90 minutes for the last 3 months	Positive change in QOLa, anxiety, and depressiona
Lu et al., 2019	Baduanjin (8 aerobic movements to balance chi, from traditional Chinese medicine) taught via videos on an app and 5 supervised sessions, with individualized prescription determined by physician; supervised (nurses trained to facilitate traditional Chinese medicine) PA 5 or more times per week for 20–40 minutes each; also included unsupervised PA	Positive change in fatiguea, sleepa, and functional statusa
Møller et al., 2015	Arm 1 received hospital-based health promotion counseling (stationary bike, ball games, dance, circuit training, and resistance exercises), arm 2 received pedometer and health-promotion counseling (walking), and arm 3 received usual care; low-, moderate-, and vigorous-intensity supervised (exercise physiologist) PA in arm 1 and unsupervised in arm 2; arm 1 had 4 sessions of 1.5–2.5 hours per week for a total training volume of 40–43 MET hours per week; arm 2 had 5 weekly sessions of 30 minutes each for a goal of 10,000 steps per day.	Negative change in fitness
Sohl et al., 2016	Yoga (awareness meditation, movement, breathing, and relaxation) delivered during chemotherapy infusion while in infusion chair and recommendations for home practice; supervised PA (yoga trainer) 3–4 times per week for 15 minutes each; also included unsupervised PA	–
Van Vulpen et al., 2016	Individualized aerobic and resistance program based on preferences and fitness level involving aerobic mode of choice and customized muscle strengthening exercises; moderate- and vigorous-intensity PA, both supervised (by physiotherapist, 2 times per week for 60 minutes each) and unsupervised (3 times per week for 30 minutes each)	Positive change in fatigue and chemotherapy completion rate; no change in QOL, anxiety, depression, and fitness
van Waart et al., 2018	Arm 1 received unsupervised, low-intensity PA selected by the participant 5 times per week for 30 minutes each, and arm 2 received supervised (nurses and physical therapists) moderate- and high-intensity resistance program; for arm 2, supervised PA was twice per week for 50 minutes each (20 minutes strength, 30 minutes aerobic), whereas unsupervised PA was 5 times per week for 30 minutes each.	Positive change in QOL, distress, fatigue, fitness, muscle strength, PA, and chemotherapy completion rate
Zimmer et al., 2018	Supervised multimodal strength and aerobic program involving balance exercises, biking, walking, and 5 station circuit strength machines; moderate- and vigorous-intensity supervised (sport therapist) PA twice per week for 60 minutes each	Positive change in fitness, muscle strengtha, endurance, and neurotoxicitya; positive and no change in balancea
Single-group pre-/post-test designs
Alejo et al., 2019	Weekly educational PA sessions at a park or hospital about benefits of PA and PA recommendations for cancer survivors; supervised moderate- to vigorous-intensity PA included walking, running, aerobic activity of choice, and strength, with goal to achieve recommended guidelines; also included unsupervised PA	Positive change in anxiety, depressiona, fitness, body mass index, PA, and sedentary behavior/inactivity; no change in QOL
Cheong et al., 2018	Self-management rehabilitation app that provides customized daily messages about medications, monitoring of side effects, scheduling of visits, and rehabilitation exercises (walking and strength) customized to a daily target of 6,000, 8,000, or 10,000 steps and minimum, moderate, or maximum resistance categories of exercises based on individualized fitness testing completed at baseline, 6, and 12 weeks	Positive change in physical performancea, PA, and nutritional status; positive and negative change in QOL; positive and no change in muscle strength
Hawkes et al., 2009	Telephone health coaching to set goals aimed at achieving national PA and diet guidelines; moderate- and vigorous-intensity patient-selected PA	Positive change in QOL, sedentary behavior, and dietary intake; negative change in body mass index, PA, and alcohol consumption; no change in smoking
Heislin & Bonanno, 2009	Individualized progressive walking program prescribed based on fitness test at baseline; moderate-intensity progressive PA 3–5 times per week for 30 minutes each	Positive change in QOL, distressa, body image, and fitness
Morielli et al., 2016	Individually prescribed supervised program with an option to transition to unsupervised program with weekly telephone calls or emails; moderate-intensity supervised (exercise specialist) PA involving treadmill, bike, elliptical, or rower 3 times per week for 50 minutes each; also included unsupervised PA	Positive and negative change in fitness; negative change in QOL
Singh et al., 2018	Individualized program with 2 supervised weekly sessions and encouragement to engage in additional independent PA to achieve PA recommendations for cancer survivors; moderate- and vigorous-intensity supervised (exercise physiologist) PA involved walking, jogging, cycling, rowing, and resistance training; also included unsupervised PA	Positive change in QOL, physical performance, muscle strength, and endurance

^aStatistically significant

app—mobile application; MET—metabolic equivalent of task; PA—physical activity; QOL—quality of life

Motivation Strategies

To motivate PA, all except one study focused on helping patients set PA goals; most (n = 13) studies also demonstrated how to engage in PA and/or had patients practice PA under supervision. All studies used credible sources (i.e., physical therapists, nurses, exercise specialists, exercise physiologists, physiotherapists, and sports therapists) to discuss PA with patients, provide instructions on how to engage in PA, and/or supervise PA. Eight studies included a combination of supervised and unsupervised PA; three included only supervised PA; four included only unsupervised PA; two compared a supervised program to an unsupervised program; and one provided an option for participants to transfer from a supervised program to an unsupervised program after six weeks of supervised instruction. Unsupervised programs were supported by a mobile application (app) (Cheong et al., 2018), telephone coaching (Hawkes et al., 2009, 2014), or a simple walking program (Heislein & Bonanno, 2009).

Benefits of Physical Activity

PSYCHOSOCIAL BENEFITS:

Across studies, mostly positive psychosocial outcomes resulted from PA interventions during chemotherapy for patients with CRC; these outcomes are improved QOL, distress, anxiety, and depression.

Of the 12 studies that measured PA effects on QOL, 9 reported positive effects. For example, in the study by Hawkes et al. (2014) (N = 410), changes in QOL scores significantly improved at 6 and 12 months postbaseline for participants receiving a telephone health coaching intervention encouraging the attainment of 10,000 daily steps compared to the control group (p = 0.049, p = 0.037, respectively). In the study by Li and Liu (2019) (N = 298), QOL scores improved significantly more for participants in a six-month telephone counseling and supervised progressive multimodal PA intervention than for the control group (p = 0.035). Two additional pilot RCTs (Backman et al., 2014; van Waart et al., 2018) and three pilot single-group pre-/post-test design studies (Hawkes et al., 2009; Heislein & Bonanno, 2009; Singh et al., 2018) reported similar positive effects of PA on QOL.

In contrast, one RCT reported PA to have no effect on QOL (Van Vulpen et al., 2016). Another single-group pre-/post-test design study reported nonsignificant mixed effects of PA on QOL during a 12-week individualized PA program that delivered customized daily step goals and resistance exercises via an app; scores increased at 6 weeks and then decreased at 12 weeks ($\overline{\mathrm{X}}=58.11$ [SD = 22.75] at baseline, $\overline{\mathrm{X}}=60.77$ [SD = 22.83] at 6 weeks, $\overline{\mathrm{X}}=57.11$ [SD = 21.29] at 12 weeks; p = 0.271) (Cheong et al., 2018). Finally, two single-group pre-/post-test design studies reported a decrease in QOL during the intervention period (Alejo et al., 2019; Morielli et al., 2016). However, because these exploratory studies lacked control groups, it is unknown whether PA protected against a potentially more severe decline in QOL. Taken together, this body of literature mostly supports that PA during chemotherapy treatment for CRC may positively affect QOL.

Two RCTs (Hawkes et al., 2014; van Waart et al., 2018) and one single-group pre-/post-test design study reported positive effects of PA on distress (Heislein & Bonanno, 2009), yet results were only significant in the study by Heislein and Bonanno (2009). However, in another non-RCT, no changes in distress were reported over the intervention period (Lin et al., 2014).

Nonsignificant decreases in anxiety were reported in one RCT (Li & Liu, 2019) and one single-group pre-/post-test design study (Alejo et al., 2019). In addition, both studies reported significant positive effects of PA on depression (Alejo et al., 2019; Li & Liu, 2019). However, in another RCT that included anxiety and depression as exploratory outcomes, no changes in anxiety or depression were noted (Van Vulpen et al., 2016). In summary, PA may lessen distress, anxiety, and depression during chemotherapy for CRC.

In addition, one RCT evaluating a telephone intervention to encourage 10,000 daily steps (N = 410) identified significant effects on measures of post-traumatic growth (p < 0.001 to p = 0.033), spirituality (p = 0.001), and acceptance (p = 0.005), as well as nonsignificant positive effects on mindfulness (Hawkes et al., 2014). Another single-group pre-/post-test study reported positive changes on body image during the intervention period (Heislein & Bonanno, 2009).

PHYSIOLOGIC OUTCOMES:

Across studies, positive changes were noted in physiologic outcomes, including fatigue, sleep, fitness, physical performance, body function/functional status, muscle strength, endurance, neurotoxicity, balance, and body mass index.

Positive effects on fatigue were reported in three RCTs (Lu et al., 2019; Van Vulpen et al., 2016; van Waart et al., 2018), but they were significant only in the study by Lu et al. (2019). However, another RCT reported no changes in fatigue (Lin et al., 2014). Positive effects on sleep were reported in one RCT (Lu et al., 2019) and one non-RCT (Loughney et al., 2017). A different non-RCT reported no changes in sleep over the intervention period (Lin et al., 2014). Taken together, findings indicate that PA may improve fatigue and sleep during treatment for CRC; at worst, it does not have any negative effects on fatigue or sleep.

Fitness improved in two RCTs (van Waart et al., 2018; Zimmer et al., 2018), one non-RCT (Lin et al., 2014), and two single-group pre-/post-test design studies (Alejo et al., 2019; Heislein & Bonanno, 2009); however, changes were not significant in any of these studies. In contrast, fitness decreased in one RCT (Møller et al., 2015) and did not change in another RCT (Van Vulpen et al., 2016); again, all effects were nonsignificant. Mixed effects on fitness were noted in a single-group pre-/post-test design study in which fitness initially decreased and then increased later in the intervention (Morielli et al., 2016). Physical performance improved in two single-group pre-/post-test design interventions (Cheong et al., 2018; Singh et al., 2018), yet changes were significant only in the study by Cheong et al. (2018). Finally, functional status significantly improved in one RCT (Lu et al., 2019). Taken together, findings indicate that PA has generally positive effects on fitness, physical performance, and functional status, warranting further exploration.

Strength increased in two RCTs (van Waart et al., 2018; Zimmer et al., 2018), one non-RCT (Lin et al., 2014), and one single-group pre-/post-test design (Singh et al., 2018); results were only significant in Zimmer et al. (2018). Endurance increased in one RCT (Zimmer et al., 2018) and one single-group pre-/post-test design study (Singh et al., 2018); changes were not significant in either study. Finally, lower extremity strength, but not upper extremity strength, significantly improved in one single-group pre-/post-test design study (Cheong et al., 2018). In summary, PA interventions during chemotherapy show positive effects on strength and endurance; additional exploration is justified.

Neurotoxicity and static balance significantly improved in one RCT; however, no changes were reported on dynamic balance (Zimmer et al., 2018). Nutritional status improved over the intervention period in one single-group pre-/post-test design study; however, improvements were not significant (Cheong et al., 2018). Finally, body mass index improved in one study (Alejo et al., 2019) and got worse in another (Hawkes et al., 2009); both studies were single-group pre-/post-test designs, and changes were not significant in either study. Overall, this body of evidence indicates that PA interventions have positive effects on the physiologic well-being of patients with CRC receiving chemotherapy.

One single-group pre-/post-test design study also included a diet component and examined effects of PA on related health behaviors; the study found nonsignificant positive effects on dietary intake, negative changes in alcohol consumption, and no change in smoking (Hawkes et al., 2009). Finally, in two RCTs, chemotherapy completion rates were better, although nonsignificant, in the intervention arm compared to the control arm (Van Vulpen et al., 2016; van Waart et al., 2018). In summary, PA intervention during chemotherapy may help chemotherapy completion rates, but there is little indication of the impact on health behaviors related to PA.

Limitations

Findings must be interpreted in the context of this review’s limitations. First, study designs and outcomes were heterogenous; thus, a meta-analysis was not conducted. Therefore, precise conclusions about the benefits of PA for patients with CRC during chemotherapy cannot be determined. Second, included studies were conducted with homogeneous study samples. Only two studies reported the race and ethnicity of participants. Therefore, this body of literature may not be relevant to individuals who are most at risk. Black individuals are more likely to develop and to die from CRC than White individuals (ACS, 2019). They are also more likely to experience CRC treatment–related side effects that may be lessened by PA, including fatigue and depression (Walling et al., 2016). Because Black patients with cancer are 60% less likely to engage in PA than White patients, efforts are particularly needed to increase PA in this population (Nayak et al., 2015).

Future Research

This review highlights the need for PA interventions that recruit and engage racially and ethnically diverse study samples so that interventions can be designed and tested in diverse patient populations—a finding that echoes the meta-analysis of Hirschey, Bryant, et al. (2020), which identified predominantly White participants in longitudinal observational studies of the predictors of PA in cancer survivors. Although this review provides a comprehensive synthesis of PA during CRC treatment, PA is only one strategy to improve symptom management and patient outcomes. PA should be included in a multimodal approach to providing patient care that may also include other modalities, such as diet, pharmaceutical drugs, complementary and alternative medicine, and hydration therapy.

Implications for Nursing

Notwithstanding these limitations, this review provides support that nurses should incorporate PA recommendations when providing holistic, person-centered care to optimize patient outcomes and QOL for patients undergoing treatment for CRC. The most common symptoms and treatment side effects experienced by patients with CRC include fatigue and neurotoxicity, gastrointestinal problems, and decreased QOL (Buccafusca et al., 2019; Stone & DeAngelis, 2016). PA not only is safe and feasible for this patient population, but also may decrease these negative effects. The incorporation of PA recommendations into caring for these patients may be particularly effective. For example, neurotoxicity can be so problematic during CRC chemotherapy treatment that it sometimes limits the completion of treatment (Velasco & Bruna, 2014). In addition, fatigue is one of the most commonly reported barriers to PA for cancer survivors (Hirschey, Nyrop, & Mayer, 2020). Initiating PA recommendations during treatment may lessen the extent of fatigue that patients experience and, in turn, allow them to engage in more PA. Informing patients that PA is safe and beneficial during radiation therapy and chemotherapy treatment for CRC may improve patients’ motivation and intention to engage to whatever level of PA is feasible for them. Other research has shown that interest in exercise during chemotherapy is associated with education about PA benefits on treatment outcomes (Avancini et al., 2020).

A person-centered approach is needed in which the clinical considerations for a particular patient guide a nurse’s recommendations for how that patient aims to achieve the minimum recommended 150 minutes of moderate- to vigorous-intensity PA per week. For example, because most patients with CRC undergo surgery to remove the tumor and many have temporary or permanent ostomies, concerns around leakage, hydration, and herniation may be discussed (Krouse et al., 2017; Mo et al., 2020; Russell, 2017, 2019). In addition, a multimodal approach to symptom management can be used to minimize side effects that may limit PA. For example, hydration therapy may assist with dehydration concerns, and antiemetics can be used to decrease nausea. Patients may be hesitant for any variety of reasons to engage in PA; therefore, small amounts of PA, with a goal to increase PA gradually, may be most appropriate (Buccafusca et al., 2019). In this review, behavior change techniques of setting goals, giving PA instructions, and grading PA were useful. Grading tasks consists of recommending easy, achievable goals of incrementally increasing difficulty (Michie et al., 2011). This may be particularly important for patients experiencing the emotional turmoil of a cancer diagnosis and treatment side effects. These findings are supported by other research that supports setting goals, giving instructions on how to engage in PA, and incrementally increasing PA from an initially small amount as the most effective strategies to increase PA among cancer survivors of multiple cancer diagnoses both on and off treatment (Bourke et al., 2014; Turner et al., 2018). Nurses can help patients set small, achievable PA goals during chemotherapy. Because large increases in PA during chemotherapy may not be realistic, small increases in PA, maintenance of current levels of PA, and even minimization of PA decline during the treatment window are important to manage treatment side effects. As a result, the severity of side effects known to hinder PA engagement in the post-treatment phase of survivorship, such as fatigue (Hirschey, Nyrop, & Mayer, 2020), may be lessened.

Conclusion

Findings indicate that PA during CRC treatment may provide psychosocial and physiologic benefits. Many different types of PA, supervised and unsupervised, have been tested in this population and are well accepted by patients. Recommending PA to patients during CRC treatment may minimize activity decline and, therefore, functional decline, improving overall outcomes. In this review, PA is highlighted as an important component for nurses to include as part of patient treatment and symptom management plans.

IMPLICATIONS FOR PRACTICE.

• Recommend that patients engage in physical activity (PA), and encourage PA goal setting during chemotherapy treatment for colorectal cancer (CRC).

• Promote that PA during chemotherapy for CRC may improve several negative side effects, including fatigue and neurotoxicity, which are particularly troublesome for patients with CRC, sometimes leading to chemotherapy dose adjustments or stoppage of therapy.

• Advise that supervised and nonsupervised interventions promoting PA for patients with CRC during treatment can provide benefit.