The impact of gynaecological cancer treatment on physical activity levels: a systematic review of observational studies

Highlights

• Physical activity does not return to pre-diagnosis level 3 years after diagnosis.

• Impact of different cancer treatments on physical activity levels remains unclear.

• Personalised physical activity guidelines are needed in gynaecological cancer.

Abstract

Background

The natural history of physical activity levels during and following gynaecological cancer treatment is not well understood. This is required in order to establish the time at which physical activity levels are lowest in order to target cancer rehabilitation or exercise interventions in gynaecological cancer population accordingly.

Objectives

To conduct a systematic review to evaluate the impact of gynaecological cancer treatments on physical activity levels and to summarise the pattern of changes in physical activity levels over time among patients with gynaecological cancer.

Methods

A comprehensive literature search was performed via MEDLINE (1946–2018), CINAHL (1982–2018), EMBASE (1947–2018), Ovid Emcare (1947–2018), PsycINFO (1806–2018) and the Cochrane Library (1991–2018). Studies were eligible for inclusion if they had assessed changes in physical activity levels during and after gynaecological cancer treatment. The methodological quality of the eligible studies was assessed by two independent reviewers using the Joanna Briggs Institute Critical Appraisal Tools.

Results

In total, six studies (three cohort studies and three cross-sectional studies) with 1607 participants were included. All studies used patient-reported physical activity measures. Two of the three cohort studies measured patient-recalled physical activity levels before diagnosis (baseline), and length of follow-up varied across all studies. The majority of participants were treated surgically ± adjuvant therapy. Physical activity levels decreased at 6 months following surgery when compared with pre-treatment levels. Approximately 91% of participants did not meet physical activity guidelines 2 years following diagnosis, and 58% reported being less physically active 3 years after diagnosis, compared with the pre-diagnosis levels.

Conclusions

Despite the paucity of evidence and limitations in the current body of literature, this review demonstrated that compared to pre-diagnosis, levels of physical activity remain low in gynaecological cancer survivors up to 3 years after diagnosis. More research is warranted to better characterise the pattern of change of physical activity levels across the disease trajectory and identify changes in physical activity patterns by cancer treatments and gynaecological tumour streams in order to target interventions accordingly.

Introduction

Worldwide, gynaecological cancer including cervical, ovarian, uterine, endometrial, vaginal, fallopian tube, placental, and vulval cancer accounts for 19% of all new female cancer cases.¹ Cervical cancer is the most common gynaecological cancer diagnosed, followed by uterine and ovarian cancers.² Treatment options for gynaecological cancer include surgery, chemotherapy, radiotherapy/brachytherapy, hormonal therapy, and/or targeted therapy.3, 4, 5 Although the aim of surgical and medical treatments for gynaecological cancer is to cure and to improve survival rates,6, 7, 8 the cancer and treatments themselves may contribute to impaired physical and psychosocial function,9, 10, 11, 12 reduced physical activity (PA) levels¹³ and low health-related quality of life (HRQoL).¹⁴

International guidelines based on strong evidence have recommended regular PA for cancer survivors to aid the process of recovery and improve fitness.15, 16 Exercise interventions are reported to improve PA levels,¹⁷ body mass index¹⁷ and HRQoL¹⁸ in patients with gynaecological cancer and are recommended to be integrated routinely into the delivery of optimal cancer care.¹⁹ However the PA recommendations for gynaecological cancer by Pennington and McTiernan¹⁹ are generic and not based on gynaecological cancer specific evidence.¹⁹ Despite the significant health benefits of exercise for cancer survivors, a previous study reports that approximately half of patients with gynaecological cancer do not meet the PA guidelines.²⁰ Fatigue, feeling “too tired” and feeling “not well enough” are commonly reported barriers.20, 21

There is emerging evidence of the potential benefits of PA on morbidity,¹⁹ risk of cancer occurrence²² and survival outcomes²³ in patients with gynaecological cancer, however research identifying PA level changes at different time-points across the gynaecological cancer continuum, and thereby, optimal opportunities for exercise interventions, is limited.²⁴ Although the long-term trends of PA levels after cancer diagnosis have been studied in several cancer populations,25, 26 the characteristics of patients with gynaecological cancer are different to other cancer cohorts in terms of a range of different pelvic organs that may be involved,²⁷ symptoms, surgical approaches, and side effects of adjuvant therapy.28, 29, 30, 31 Women with gynaecological cancer also tend to feel differently from the general cancer community due to the influence of cancer type, cancer site, and treatment type on their experiences. This includes being embarrassed about their cancer site and marginalised if they have had an adjuvant treatment the community is unfamiliar with, such as brachytherapy.²⁸ As PA, a modifiable lifestyle factor, plays a critical role in gynaecological cancer survivorship,¹⁹ a better understanding of the natural history of PA levels following gynaecological cancer treatment will potentially improve gynaecological cancer rehabilitation and prevent the sequelae of physical inactivity and non-communicable chronic diseases that may develop with ageing.³²

Therefore, we aimed to conduct a systematic review to evaluate the impact of gynaecological cancer treatments on PA levels and to summarise the pattern of changes in PA levels at different time-points across the gynaecological cancer continuum. This review will assist health professionals and researchers better understand the natural history of PA levels in this population, identify times of low PA, and recommend strategies to address this problem.