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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

LIMIT to English Language

Search Outcome

85 hits, 13 relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Thorsen, L et al April 2005 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
Mishra S et al 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.
Lahart IM et al 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
Mishra S et al 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
Krouse R et al 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.
Braam K 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
Sammut L et al 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
Buffart L et al 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
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
Spence R et al 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
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)
Morgan R 2014 USA	Cancer Survivors	Report	QoL	Physical activity significantly improves QoL during and after treatment for cancer	Few references to support article
Voskuil DW et al 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

Comment(s)

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.

Clinical 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 Journal of Clinical Oncology 2005; 23;10;2376-2388
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) Cochrane Library
3. Lahart IM, Metsios G, Nevill A, Carmichael A Physical activity for women with breast cancer after adjuvant therapy (review) Cochrane Library 2018
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 Cochrane Library
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 Qual Life Res 2017; 26; 3131-3142
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 Cochrane Library 2016
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 Clinical Otolaryngology 2015; 41; 241-248
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 Cancer Treatment Reviews 2014; 327-340
9. Roland N, Rogers S Exercise interventions of health related quality of life for cancer suvivors Clinical Otolaryngology
10. Spence R, Heesch K, Brown W Exercise and Cancer rehabilitation: a systematic review Cancer Treatment Reviews 2010; 185-194
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 Plos One 2012; 7(5) ; e36164
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 Journal of National Comprehensive Cancer Network 2017; 735-737
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 American Association of Cancer Research