What is the current evidence for the use of cycling to improve quality of life in adolescent cancer patients both during and after treatment?

Date First Published:
November 28, 2018
Last Updated:
December 12, 2018
Report by:
Rebecca Pickford, Senior Physiotherapist (University College London Hospitals)
Three-Part Question:
What is the current evidence for the [use of cycling] to improve [quality of life] in [adolescent cancer patients both during and after treatment]?
Clinical Scenario:
A 14 year old girl is admitted to the Macmillan Cancer Centre for a cycle of MAP chemotherapy. She has recently undergone limb salvage surgery for a distal femoral tumour and is now undergoing rehabilitation and struggling with being unable to do activities which she found easy before, this in turn is impacting on her mood and quality of life. You wonder if there is evidence to support the use of cycling to aid return to function and improve quality of life after surgery
Search Strategy:
Cochrane, NICE, Embase, Medline and Physiotherapy Evidence Database (PEDro) were searched using the terms: ‘bicycling OR cycling OR exercise bike’, ‘quality of life’, ‘cancer’
Cochrane library: 31 studies, 3 relevant
NICE: 0 studies
Embase: 47 papers, 10 relevant
Medline: 2 papers, 1 relevant
PEDro: 5 papers 1 relevant
Hand Searching: nil new
After duplicates removed 13 papers
Search Details:
LIMIT to English Language
Outcome:
85 hits, 13 relevant
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Effectiveness of Physical Activity on Cardiorespiratory Fitness and Health-Related Quality of Life in Young and middle aged cancer patients shortly after Chemotherapy Thorsen L, Skovhand E, Stromme S, Hernslien K, Dahl A, Fossa S Apr-05 Norway 139 Lymphoma, breast Ca, gynaelogic or testicular Ca patients RCT

14 week training programme including cycling vs. standard care
 Astrand-rhyming indirect test Significant difference found between groups for CRF Patients included in trial were relatively well and not limited by severe disease.
Lack of follow up data available
High drop-out rate 10 in intervention group, 18 in control group
EORTC QLQ-C30 no significant difference
HADS no significant difference
fatigue significantly higher levels of fatigue in intervention group
Exercise Interventions on Health-related quality of life for cancer survivors (review) Mishra S, Scherer RW, Geigle PM, Bertanstein DR, Topaloglu, Gotay CC, Snyder C 2012 USA 3694 breast, colorectal, head and neck, lymphoma and other Ca diagnoses who had finished treatment Cochrane review
40 trials randomised to exercise or control

Exercise interventions included cycling
QoL Exercise compared to control has a positive impact on HRQoL at 12 weeks CI 0.16-0.81 and at 6 month follow up CI 0.09-0.84 Not looking at follow up after cancer treatment finished – lack of long term data
Lots of different types of exercise included therefore unable to state which intervention is the most effective to improve HRQoL. Similarly different outcome measures used and difficult to analyse.
Physical activity for women with breast cancer after adjuvant therapy (review) Lahart IM, Metsios G, Nevill A, Carmichael A 2018 UK 5761 women with breast ca Cochrane review

63 trials physical activity vs control group
 QoL Physical activity has significant small to moderate beneficial effects on HRQoL 95% CI 0.21-0.57 Low quality evidence
High risk of bias in trials
Exercise interventions on health-related quality of life for people with cancer during active treatment Mishra S, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O 2012 USA 4826 participants breast, prostate, gynaelogic, haematologic and other cancer patients undergoing active treatment Cochrane review

56 trials

Exercise vs comparison
 QoL Exercise has significant positive impact on overall HRQoL with improvement from baseline to 12 week follow up. moderate to vigorous activity lead to larger changes in QoL High risk of bias in papers included

Exercise interventioins varied in length and intensity
Different outcome measures for QoL
Short follow up period
fatigue Significant decrease in fatigue
Physical activity, bowel function and quality of life among rectal cancer survivors Krouse R, Wendel C, Garcia D, Grant M, Temple L, Going S, Hornbrook M, Bulkley J, McMullen C, Herrinton L 2017 USA 574 rectal cancer survivors Survey collection QoL HRQoL outcomes rose significantly with physical activity. particularly an increase in psychological wellbeing and increased feeling of control CI 0.10-0.76 High risk of bias with self-reporting questionnaire
Low response rate – 60%
Unable to capture data regarding increasing age and comorbidities and their impact on PA
Outcomes tailored to ACSM guidelines therefore could be missing impact on patients who complete little/no PA.
Physical exercise training interventions for children and young adults during and after treatment for childhood cancer Braam K, van der Torre P, Takken T, Veening M, van Dulmen-den Broeder E, Kaspers GJL 2016 netherlands 171 children/YA during treatment for ALL Cochrane review

6 papers
Exercise vs control
 QoL no change in HRQoL Small sample sizes
Unclear randomisation
Single blinding
Low-moderate quality studies
Cardiorespiratory fitness - 9 minute walk-run test significant increase in cardio respiratory fitness in intervention group CI 0.02-1.35
muscle strength significant increase in muscle strength in back and leg muscles 95% CI 0.71-2.11
Participation in sport and physical activity in head and neck cancer survivors: associations with quality of life Sammut L, Fraser L, Ward M, Singh T, Patel N 2015 UK 172 participants with head and neck cancers Questionnaire Physical activity statisiticaly significant reduction in physical activity levels after diagnosis/treatment (64% at start of treatment vs 40.1% at End of Treatment) Self-reported questionnaire leading to high risk of bias
No data with regards to stage of H&N cancer, effect of NG tube, nutrition – all likely to impact on QoL
QOL statistically significant increase in QoL for those who completed higher levels of PA (p<0.05). Cycling and swimming most common types of exercise pre and post treatment
Evidence-based physical activity guidelines for cancer survivors: current guidelines, knowledge gaps and future research directions Buffart L, Galvao D, Brug J, Chinapaw M, Newton R 2013 Netherlands Review of 6 guidelines 2003-2012
16 RCTs – 2339 participants – prostate, testicular, colon, breast ca patients
 Review QoL Significant improvements in QoL can be expected when increasing activity levels No evidence of search strategy for literature
Small number of studies/guidelines to review
Exercise interventions of health related quality of life for cancer suvivors Roland N, Rogers S 2012 UK 8 studies cancer survivors - not documented population numbers Editorial comment QoL Exercise can increase QoL - not significant No evidence of search criteria/strategy
Trials are small and of poor quality
No mention of specific outcome measures
Exercise and Cancer rehabilitation: a systematic review Spence R, Heesch K, Brown W 2010 Austrailia Breast, gynae, colorectal, lymphoma and testicular Ca participants Systematic review – 13 articles physical function significant improvements seen in physical function Small sample sizes – average 42
Poor quality trials
Heterogeneity in populations, exercise programmes, outcomes and follow up period
Only one study looking specifically at QoL all others include it as a secondary outcome
Fatigue no fatigue reported in patients who were allocated daily exercise compared with 25% in the control group
QoL significantly greater QoL in all domains in patients who completed 3 months of aerobic and resistance training
body composition significant decrease in fat free mass in intervention group
Self-reported physical activity: Its correlates and relationship with health-related quality of life in a large cohort of colorectal cancer survivors Buffart L 2012 Netherlands 1371 participants with colorectal cancer Questionnaires – cross sectional HRQoL Significantly improved QoL with regular moderate-vigorous physical activity(p<0.05) Younger and predominantly male participants
Early stages of cancer (I & II)
fatigue significantly lower fatigue in those who regularly do moderate-vigorous physical activity (p<0.05)
Underserved topics in oncology: the role of physical activity in improving quality of life and disease recurrence risk in patients with cancer Morgan R 2014 USA Cancer Survivors Report QoL Physical activity significantly improves QoL during and after treatment for cancer Few references to support article
Physical activity to maintain quality of life in breast cancer survivors in the Dutch Tamoxifen Exemestane Adjuvant Multicentre (TEAM) trial DW Voskuil, JG van Nes, JM Junggeburt, FE van Leeuwen, CJ van de Velde and HC de Haes 2009 Netherlands 543 breast cancer patients Poster abstract QoL no clinically significant changes in QoL Only abstract available therefore unable to assess statistical analysis and methodology
Author Commentary:
The current evidence for cycling in cancer patients to improve quality of life is limited with most evidence including cycling as an exercise option and not looking at this specifically. There is even less evidence looking at the adolescent population. There is also a lack of high quality RCTs which are required to allow for standardised guidelines to be set in place.
Bottom Line:
Current evidence suggests that exercise can improve quality of life in patients undergoing treatment and those who have finished treatment however there is limited evidence to say what type of exercise is best and when is best to start this intervention along with how long this intervention should last. This conclusion is based on limited moderate-low quality evidence and further clinical studies and RCTs are required in this area.
References:
  1. Thorsen L, Skovhand E, Stromme S, Hernslien K, Dahl A, Fossa S. Effectiveness of Physical Activity on Cardiorespiratory Fitness and Health-Related Quality of Life in Young and middle aged cancer patients shortly after Chemotherapy
  2. Mishra S, Scherer RW, Geigle PM, Bertanstein DR, Topaloglu, Gotay CC, Snyder C. Exercise Interventions on Health-related quality of life for cancer survivors (review)
  3. Lahart IM, Metsios G, Nevill A, Carmichael A. Physical activity for women with breast cancer after adjuvant therapy (review)
  4. Mishra S, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O. Exercise interventions on health-related quality of life for people with cancer during active treatment
  5. Krouse R, Wendel C, Garcia D, Grant M, Temple L, Going S, Hornbrook M, Bulkley J, McMullen C, Herrinton L. Physical activity, bowel function and quality of life among rectal cancer survivors
  6. Braam K, van der Torre P, Takken T, Veening M, van Dulmen-den Broeder E, Kaspers GJL. Physical exercise training interventions for children and young adults during and after treatment for childhood cancer
  7. Sammut L, Fraser L, Ward M, Singh T, Patel N. Participation in sport and physical activity in head and neck cancer survivors: associations with quality of life
  8. Buffart L, Galvao D, Brug J, Chinapaw M, Newton R. Evidence-based physical activity guidelines for cancer survivors: current guidelines, knowledge gaps and future research directions
  9. Roland N, Rogers S. Exercise interventions of health related quality of life for cancer suvivors
  10. Spence R, Heesch K, Brown W. Exercise and Cancer rehabilitation: a systematic review
  11. Buffart L. Self-reported physical activity: Its correlates and relationship with health-related quality of life in a large cohort of colorectal cancer survivors
  12. Morgan R. Underserved topics in oncology: the role of physical activity in improving quality of life and disease recurrence risk in patients with cancer
  13. DW Voskuil, JG van Nes, JM Junggeburt, FE van Leeuwen, CJ van de Velde and HC de Haes. Physical activity to maintain quality of life in breast cancer survivors in the Dutch Tamoxifen Exemestane Adjuvant Multicentre (TEAM) trial