DISCUSSION
The importance of physical activity for individuals during and after
cancer care has been increasingly recognized. It has favorable effects
on various levels of functioning, encompassing aspects of QoL, mood
symptoms, fitness level, muscle strength, body composition, and active
attainment of social roles.5,7,8,12,24,30,31 A
possible relationship between the level of fitness and the risk of both
mortality4 and tumor recurrence11,32has also emerged, and is worth exploring.
We know that adolescent and young adults with cancer are less active
than their healthy peers (especially when in hospital), and that many of
them experience important morbidities while receiving
treatment.3,28,29
Fatigue has multiple dimensions that may involve physical,
psychological, social and cognitive aspects of the person affected.
Consequences of fatigue causes the inability to engage in everyday life
activities and social roles (including educational and work
opportunities),
mood
swings, sleep disturbances,
impaired relations,
lower academic achievement, and
impaired QoL.21,22 Among pediatric patients receiving
cancer treatments, fatigue is more prevalent in adolescents, and might
be particularly important in this age group.20,33
When interviewed at the baseline, 97.5% of our patients who were active
before being diagnosed with cancer reported a substantial decline in
their exercising and sports activities compared with their previous
levels: the main reasons mentioned for abandoning included fatigue, lack
of time, and physical disabilities. It is noteworthy that 42% of these
patients suspended their physical activities because they had been told,
wrongly, that they were contraindicated for cancer patients. This is a
common misconception even among general practitioners.
The purpose of our study was to explore the potential effects of an
organized exercise program for children and adolescents at a
comprehensive cancer center (where a structured exercise program is
available28) on patients’ self-reported HRQoL and
fatigue.
Our findings indicate that patients who attended the exercise sessions
(our GYM group) perceived a better emotional functioning than those who
did not, obtaining significantly better scores especially forfear , sadness , sleeping difficulties , anduncertainty about the future . We know that the benefits of
exercising and practicing sports go far beyond physical function
endpoints alone, but there are still gaps in our understanding of how
they benefit the emotional and social spheres, and resilience as
well.13,27 A key finding in a study on a large cohort
of childhood cancer survivors was that vigorous exercise was associated
with a lower risk of depression, somatization, and cognitive
impairment.31 Training for a sports competition might
symbolize patients’ return to setting themselves healthy and challenging
plans for their future. Endorphins, endocannabinoids, monoamines, and
neurotrophins have all been implicated in the euphoric response to
endurance running,34 and may reinforce the biological
rationale behind some of our findings.35 Other
investigations have suggested that cardiorespiratory fitness may
directly affect brain function, or have attributed the psychological
benefits of exercise to improvements in sleep duration or
quality.36
Looking at the positive effects of exercising on emotionalhealth, martial arts classes that were recently added to our in-hospital
exercise programs13 have proved an interesting way to
empower our patients emotionally too, improving their breathing and
relaxation skills. During these classes, most of the work aims to help
young patients to cope with feelings of pain, anger, anxiety, fear, loss
of control, and diminished self-esteem. Interestingly, a
panel of experts made a strong
recommendation for the use of relaxation techniques or mindfulness, or
both, to manage cancer-related fatigue, based on consistent findings
concerning the benefits of these practices across different types of
adult patients and intervention.23
A better emotional health and self-esteem can also relate to a
better social functioning. Patients in our GYM group had better scores
for some items referring to social functioning (e.g.getting along with peers , making friends ). For adolescents
especially, the benefits of engaging in sports might include regaining a
sense of having a lively, properly-functioning body, enhancing
relationship with peers and a sense of independence. These findings are
in line with research demonstrating positive relationships between
physical activity and cognitive outcomes.24–26,37
For the youngest children, integrating physical education in hospital
routines may also be important not only to promote physiological motor
development,38,39 but also to preserve or restore a
normality that cancer patients often lack, such as a chance to play with
friends like during gym classes at school. It is important to identify
approaches to patients’ safe practice of physical activities, taking
into account their age-specific preferences. We know that encouraging
physical activity in small children is challenging, but we found that
children as young as 5 years old could take an active part in the
workout sessions considered in the present study.
On the other hand, our GYM group had worse scores than the No-GYM group
for the item that concerned being able to do what peers can do .
In principle, everybody can find a suitable form of exercise or sport to
practice, though a delicate balance has to be struck between
individuals’ wishes and their capabilities (which may have been
irreparably affected by their cancer). This may demand adapting certain
sports to patients with disabilities, or providing parallel
psychological support in some circumstances. Asking patients to exercise
may exacerbate their frustrations if the demands placed on them exceed
their expected capabilities, especially if prescribed levels of physical
fitness are aligned with those enjoyed by a patient before they were
diagnosed with cancer.
Our two groups (GYM and No-GYM) differed in terms of cancer types.
Indeed patients with brain tumors – who are known to suffer from
neuromotor impairments40 - seemed more reluctant to
attend the gym (6 out of 8 such patients refused).
Professionally-supervised programs need to be developed to accommodate
underlying organ system impairments, so that alternative, customized
workouts can be used to exercise the less impaired parts of a patient’s
body. It is worth noting, for instance, how any lower limb impairment
preventing a patient from walking tended to be misconceived as a major
reason for not exercising at all because such patients were unable to
walk, run, jump, or kick a ball (but they could work out effectively
with their upper limbs and trunk).
The strengths of our study include our having examined several
dimensions of HRQoL and fatigue, and the correlations between the three
dimensions of physical health, psychological functioning and fatigue as
a whole. Individuals who have a more positive perception of their
neurocognitive functioning may also experience greater self-efficacy,
and this would make it easier for them to engage in exercising. The
direct correlation identified in our sample between a better perceived
physical functioning and a greater perception of fatigue probably stems
from the fact that patients motivated to exercise and try to overcome
their limits also had a more acute awareness of these limits and their
sense of fatigue.
Our findings indicate that children attending the gym scored worse on
fatigue, except for general fatigue . Analyzing the single items
in the questionnaire showed that the median scores were better in the
GYM group for perceived quality of sleep and daily
fatigue . The effect of exercise on the severity of fatigue may differ,
depending on the type of activity involved (aerobic, neuromotor, or
combined exercises might be more effective in containing fatigue than
resistance exercises23), and the intensity of the
exercise. Given the very heterogeneous nature of cancer populations,
recent publications have called for a more precise manipulation of
training variables - such as volume, intensity, and frequency - to truly
optimize clinically-relevant patient-reported
outcomes.10 We did not homogeneously prescribe or
record the training parameters adopted in our sample, however, so we are
unable to say which type of exercise might be best exercise for the
study outcomes, or why scores for fatigue were worse for the GYM group.
There are other limitations in our study to acknowledge. Patients were
assigned to one of the two groups being compared not randomly, but based
on their volunteering for the exercise program. The patients’ reasons
for attending the training sessions may have been positively or
negatively influenced by their ability (or fear of inability) to cope
with the exercises, or by their attitude to sports before becoming ill
(although a similar proportion of patients in the GYM and No-GYM groups
had not exercised regularly before being diagnosed with cancer). Our
patients also formed a very heterogeneous group, with ages ranging from
5 to 21 years. They had different types of solid tumor, and received
different treatments, sometimes involving surgery and radiotherapy as
well as chemotherapy (which was administered to all participants in the
study). This means that any differences between the GYM and No-GYM
groups may not be attributable to our exercise program alone, but also
to other factors not assessed (e.g., changes in health status,
medication, or other cancer treatments).
A further limitation includes the fact that no longitudinal data were
available (to enable any within-subject comparison between before and
after the 6-week exercise program in the self-reported QoL outcomes for
patients in the GYM group).
We hope our findings will attract attention to the feasibility and
possible benefits of promoting more systematic opportunities to move and
exercise for young cancer patients, even during their active treatment,
to improve their self-reported physical and psychosocial symptoms and
HRQoL, and especially their emotional functioning. It is likely that
keeping physically active helps. The results of our baseline survey also
suggest that many young patients with cancer, their parents, and their
doctors feel that a diagnosis of cancer makes it unsafe or unfeasible to
exercise and practice sports, but this is a modifiable barrier.
CONFLICTS OF INTEREST STATEMENT: The authors have no conflict
of interest to disclose.
AVAILABILITY OF DATA AND MATERIAL The datasets generated and/or
analyzed as part of the present study are available from the
corresponding author on reasonable request.
ACKNOWLEDGMENTS: We thank the Associazione Bianca Garavaglia
Onlus for their constant financial support. We are also grateful to
Gloria and Pasquale, sport professionals, who assist our patients with
tailored workouts and constant commitment. The research was partially
supported by a private grant from the Associazione Bianca Garavaglia
onlus (salaries for sports professionals).