Physical activity interventions for the physical and mental health of people during and after treatment for bowel cancer

Background

Bowel cancer is the third most common cancer diagnosed worldwide. Being diagnosed and receiving treatment for bowel cancer can have a negative impact on a person's physical and mental health. Side effects include reduced fitness levels and increased tiredness. People are also at risk of their cancer returning after treatment and this can cause fear and worry. Research on physical activity programmes in other cancer populations has shown benefits in reducing side effects of treatment. Given that people who are active have a lower chance of developing bowel cancer, physical activity may be beneficial for those with a bowel cancer diagnosis, but the research is not yet clear.

Review question

This review was undertaken to find out whether physical activity programmes are beneficial for the physical and mental health of people with bowel cancer and whether they are safe.

Key results
We found 16 studies that included 992 participants, our evidence is current to June 2019. Participants were randomly assigned to receive a physical activity programme or usual care (no physical activity programme). In the included studies, we are unsure whether physical activity programmes improve physical function and we found no effect of physical activity programmes compared to usual care on disease-related mental health. No serious adverse events occurred in the eight studies that looked at adverse events. There was inconsistency in reporting and measurement of adverse events. We do not know whether physical activity improves survival at any time point as no studies looked at this. The included studies suggest physical activity programmes may increase aerobic fitness, health-related quality of life (general well-being) and reduce fatigue (tiredness) in the short term. We are unsure of the long-term effects of physical activity interventions on physical function, disease-related mental health, adverse events, physical fitness, fatigue (tiredness), weight, health-related quality of life (general well-being) and physical activity levels because no studies assessed this.

Quality of the evidence
We rated the quality of the evidence from very low to moderate mainly because of the small number of studies and low number of participants, as well as study limitations.

Conclusion
The findings of this review should be interpreted with caution due to the low number of studies included and the quality of the evidence. This review shows the need for future high quality research with longer-term follow-up to assess the effects of physical activity interventions on the physical and mental health of people with bowel cancer, especially in relation to safety and survival.

Authors' conclusions: 

The findings of this review should be interpreted with caution due to the low number of studies included and the quality of the evidence. We are uncertain whether physical activity interventions improve physical function. Physical activity interventions may have no effect on disease-related mental health. Physical activity interventions may be beneficial for aerobic fitness, cancer-related fatigue and health-related quality of life up to six months follow-up. Where reported, adverse events were generally minor. Adequately powered RCTs of high methodological quality with longer-term follow-up are required to assess the effect of physical activity interventions on the disease-related physical and mental health and on survival of people with non-advanced colorectal cancer. Adverse events should be adequately reported.


Read the full abstract...
Background: 

Colorectal cancer is the third most commonly diagnosed cancer worldwide. A diagnosis of colorectal cancer and subsequent treatment can adversely affect an individuals physical and mental health. Benefits of physical activity interventions in alleviating treatment side effects have been demonstrated in other cancer populations. Given that regular physical activity can decrease the risk of colorectal cancer, and cardiovascular fitness is a strong predictor of all-cause and cancer mortality risk, physical activity interventions may have a role to play in the colorectal cancer control continuum. Evidence of the efficacy of physical activity interventions in this population remains unclear.

Objectives: 

To assess the effectiveness and safety of physical activity interventions on the disease-related physical and mental health of individuals diagnosed with non-advanced colorectal cancer, staged as T1-4 N0-2 M0, treated surgically or with neoadjuvant or adjuvant therapy (i.e. chemotherapy, radiotherapy or chemoradiotherapy), or both.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 6), along with OVID MEDLINE, six other databases and four trial registries with no language or date restrictions. We screened reference lists of relevant publications and handsearched meeting abstracts and conference proceedings of relevant organisations for additional relevant studies. All searches were completed between 6 June and 14 June 2019.

Selection criteria: 

We included randomised control trials (RCTs) and cluster-RCTs comparing physical activity interventions, to usual care or no physical activity intervention in adults with non-advanced colorectal cancer.

Data collection and analysis: 

Two review authors independently selected studies, performed the data extraction, assessed the risk of bias and rated the quality of the studies using GRADE criteria. We pooled data for meta-analyses by length of follow-up, reported as mean differences (MDs) or standardised mean differences (SMDs) using random-effects wherever possible, or the fixed-effect model, where appropriate. If a meta‐analysis was not possible, we synthesised studies narratively.

Main results: 

We identified 16 RCTs, involving 992 participants; 524 were allocated to a physical activity intervention group and 468 to a usual care control group. The mean age of participants ranged between 51 and 69 years. Ten studies included participants who had finished active treatment, two studies included participants who were receiving active treatment, two studies included both those receiving and finished active treatment. It was unclear whether participants were receiving or finished treatment in two studies. Type, setting and duration of physical activity intervention varied between trials. Three studies opted for supervised interventions, five for home-based self-directed interventions and seven studies opted for a combination of supervised and self-directed programmes. One study did not report the intervention setting. The most common intervention duration was 12 weeks (7 studies). Type of physical activity included walking, cycling, resistance exercise, yoga and core stabilisation exercise.

Most of the uncertainty in judging study bias came from a lack of clarity around allocation concealment and blinding of outcome assessors. Blinding of participants and personnel was not possible. The quality of the evidence ranged from very low to moderate overall. We did not pool physical function results at immediate-term follow-up due to considerable variation in results and inconsistency of direction of effect. We are uncertain whether physical activity interventions improve physical function compared with usual care. We found no evidence of effect of physical activity interventions compared to usual care on disease-related mental health (anxiety: SMD -0.11, 95% confidence interval (CI) -0.40 to 0.18; 4 studies, 198 participants; I2 = 0%; and depression: SMD -0.21, 95% CI -0.50 to 0.08; 4 studies, 198 participants; I2 = 0%; moderate-quality evidence) at short- or medium-term follow-up. Seven studies reported on adverse events. We did not pool adverse events due to inconsistency in reporting and measurement. We found no evidence of serious adverse events in the intervention or usual care groups. Minor adverse events, such as neck, back and muscle pain were most commonly reported. No studies reported on overall survival or recurrence-free survival and no studies assessed outcomes at long-term follow-up

We found evidence of positive effects of physical activity interventions on the aerobic fitness component of physical fitness (SMD 0.82, 95% CI 0.34 to 1.29; 7 studies, 295; I2 = 68%; low-quality evidence), cancer-related fatigue (MD 2.16, 95% CI 0.18 to 4.15; 6 studies, 230 participants; I2 = 18%; low-quality evidence) and health-related quality of life (SMD 0.36, 95% CI 0.10 to 0.62; 6 studies, 230 participants; I2 = 0%; moderate-quality evidence) at immediate-term follow-up. These positive effects were also observed at short-term follow-up but not medium-term follow-up. Only three studies reported medium-term follow-up for cancer-related fatigue and health-related quality of life.

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