A Scoping Review of Physical Activity and Exercise Initiatives for Cancer Patients in Ireland.

Background
Improved early detection and treatment has led to an increase in the numbers of people surviving cancer and it is estimated that 200,000 patients previously diagnosed with cancer were living in Ireland at the
end of 2019 (National Cancer Registry Ireland, 2021). Ireland’s National Cancer Strategy (2017‐2026) aims to improve cancer outcomes for the Irish population and with increased survival rates comes an increase in the number of individuals concerned with their quality of life in survivorship and potentially living with the side effects of cancer and its treatment. These side effects can include declines in cardiorespiratory fitness and physical function, adverse changes in body composition, and fatigue, neuropathy, pain and lymphoedema (Ligibel et al., 2022). These side effects may have detrimental effects on functional capacity and quality of life (QoL), but also cause cancer survivors to be susceptible to
comorbidities such as cardiovascular disease (CVD), diabetes (Ligibel et al., 2022) and increased risk of secondary cancers (Siegel et al., 2022).

The National Cancer Control Programme (NCCP) commissioned this scoping review of existing physical activity and exercise programmes in Ireland to determine the current provision in this area. A strategic
steering group was set up to support the work with key stakeholders including patients and knowledge experts. This steering group was available to feedback, oversee and support the work of the research
group.

Introduction
One strategy that can have positive effects across the cancer journey is to engage patients and survivors in physical activity (PA). PA can mitigate many of the effects of cancer treatments. There is consistent
evidence for the effectiveness of exercise interventions during active treatment across cancer types to maintain or improve cardiorespiratory fitness (Bjorke et al., 2019; Scott et al., 2018) and physical function
(Sweegers et al., 2018). PA interventions during treatment also reduce fatigue (Oberoi et al., 2018; Hilfiker et al., 2018). There has also been increasing interest in the benefits of PA prior to surgery or treatment (often referred to as prehabilitation) for cancer patients to reduce post‐operative stress, duration of hospital stays and improve cardiopulmonary function (Carli & Scheede‐Bergdahl, 2015; Nelson et al., 2019). Being physically active post diagnosis and post treatment is vital to reduce the risks of cancer‐specific and all‐cause mortality and improve survival (Patel et al., 2019). Cancer survivors who
are physically active have lower CVD‐related morbidity, lower recurrence risk, and improved survival compared to those who are inactive (Keats et al., 2016; Brown & Gilmore, 2020). Given the myriad of benefits of PA, several international guidelines recommend PA for those living with and beyond cancer (Campbell et al., 2019; Rock et al., 2022; Campbell et al., 2011). The American Cancer Society recommends that adult cancer survivors participate in 150 minutes of aerobic moderate‐intensity PA per week and muscle‐strengthening activities on two or more days a week (Rock et al., 2022) for improved health outcomes and longevity. The American College of Sports Medicine (ACSM) have also
proposed similar exercise recommendations (i.e., moderate‐intensity aerobic PA such as brisk walking three times per week and twice‐weekly resistance training) for targeting specific symptoms for those undergoing cancer treatment such as fatigue, anxiety, depression, QoL, physical function, sleep, and bone health (Campbell et al., 2019). Physical activity is also recommended for those living with advanced
cancer to maintain or improve physical function and QoL with an ACSM guideline making five recommendations for this cohort in addition to the standard PA recommendations (Campbell et al., 2022).

The above recommendations have been developed based on the conclusion that exercise is generally safe for cancer survivors and is therefore, suitable for the majority of patients. There is a small proportion of cancer survivors who may be unable to achieve or tolerate the recommendations due to the nature and extent of their side effects and physical limitations (Campbell et al., 2019). Patients with complex
needs may require more individualised or intensive rehabilitation and appropriate assessment can inform suitable modifications to an individual’s PA prescription (Schmitz et al., 2019). Every cancer survivor
should avoid inactivity (Campbell et al., 2019). Despite the increasing evidence that PA improves cancer outcomes, international literature indicates that most survivors (~75%) fail to meet the PA guidelines. Therefore, efforts and resources need to be made to find strategies to effectively promote PA to cancer survivors across the cancer continuum.

A first step is the identification of existing PA provision for cancer survivors living in Ireland and an exploration of the main barriers to PA promotion to form national recommendations in this area.

Aim of Scoping Review
The aims of the scoping review were to:
• identify the existing cancer‐related PA services and programmes in Ireland across the cancer continuum
• identify gaps in current provision and the differences between research‐led interventions and existing community or facility‐based programmes
• identify potential ways to expand PA services for cancer in Ireland
• identify the main barriers to PA promotion in cancer survivors and potential solutions
• propose national recommendations and strategies to implement PA programmes and services in this area.

Methodology
The methodological approach included three stages.

Stage 1. The first stage involved a scoping review to identify current provision of exercise programmes and PA services in Ireland.
Stage 2. The second stage involved a review of systematic reviews of international literature on the types and effectiveness of PA interventions in cancer survivors to identify evidence‐based interventions in this area. PA was chosen as the primary outcome to delimit the scope of the literature review. This was to ensure a manageable output in the timeframe of the project. The literature has focused on the effects of PA on numerous outcomes in cancer patients and PA is beneficial at all stages of the cancer journey. However, once short‐term interventions are complete, the effect on PA behaviour is important to maintain health outcomes and to provide more long‐term health benefits and survival.
Stage 3. The final stage involved roundtable discussions with a variety of stakeholders to identify barriers to PA promotion and potential solutions concerning the expansion of PA services for cancer in Ireland.
Based on the findings from these three stages, potential strategies on the way forward and national recommendations to implement PA programmes and services in this area were proposed.

Key Findings
1. The results from this scoping review indicate that availability of existing community exercise provision and PA interventions nationally in this area is limited. Limited access to PA programmes included availability in general, but also the costs of referral to some community programmes.
2. It is apparent that most cancer survivors do not routinely receive PA assessment, information, advice, or counselling as part of usual care and that referral to PA programmes is not standard practice.
3. There are some existing exercise programmes available for cancer survivors in the community and in some hospitals. However, most existing PA services are not consistently available. Overall, there
is very little dedicated PA provision for cancer survivors.
4. Little is known concerning the overall effectiveness of existing PA services for cancer survivors within community or hospital settings in Ireland. Research in exercise oncology in Ireland is limited
to a small number of settings and tumour groups, with both positive and mixed findings in terms of
efficacy.
5. There have been few eHealth and mHealth interventions in Ireland yet internationally there is growing support for the efficacy of wearable interventions to increase PA in cancer survivors.
Similarly, few PA interventions in Ireland have been based on a theory of behaviour change or utilised counselling approaches.
6. The primary barriers to PA promotion in cancer survivorship included (i) a lack of awareness by healthcare professionals concerning the importance of and benefits of PA in cancer, (ii) a lack of
knowledge concerning the PA guidelines for cancer survivors including ways to effectively counsel patients for exercise, and (iii) a lack of availability of PA programmes or services specifically for cancer survivors.
7. There was little referral to existing community exercise programmes by consultants and hospital staff, and the lack of a simple triage and referral mechanism for healthcare professionals was noted as a barrier to referral.
8. The dominant mode internationally and in Ireland has been the delivery of facility and group‐based exercise programmes for cancer survivors. However, access and cost were identified as barriers to
facility‐based programmes and there was recognition that many survivors prefer individual 1:1 support and programmes.
9. The NCCP was viewed as the entity with the authority to ensure that PA promotion becomes part of routine practice in the oncology setting and integrated into the cancer pathway nationally.