The number of cancer survivors, defined as individuals with cancer from diagnosis through death,1 has increased markedly in recent decades and will reach an estimated 18 million worldwide by 2022.2 Cancer survivors experience a wide range of physical and psychological symptoms due to their underlying malignancies and associated treatments.1,3,4 Exercise is a promising intervention to prevent and ameliorate cancer- and treatment-related toxicities.5 Prior studies,6–11 including a systematic review of 34 exercise interventions for patients with cancer during and after treatments,6 report that exercise in survivors improves strength, endurance, and cardiopulmonary function, thereby resulting in improved physical and mental health and health-related quality of life (HRQoL). Based on these benefits, efforts to integrate exercise interventions in cancer care are increasing.1,12 These interventions can be delivered in prescriptions that define exercise mode, duration, frequency, and intensity as part of routine cancer care.
Poor adherence to exercise interventions is a major barrier to achieving the optimal benefits of exercise.13–16 The presence of symptoms related to cancer and its treatments, including fatigue, depression, insomnia, and pain, may further hinder cancer survivors' exercise intervention adherence.13 Multiple studies suggest that self-efficacy is an independent predictor of exercise adherence in the general population17,18 and in patients with illnesses, including chronic obstructive pulmonary disease,19 obesity,20 congestive heart failure,21 stroke,22 type 2 diabetes mellitus,23 and cancer.24 There is, therefore, interest in identifying ways of increasing self-efficacy.
Exercise interventions using digital activity trackers (E-DATs), including digital healthcare-related wearable sensors, digital processing applications (apps), or communication equipment,25 may improve self-efficacy of cancer survivors, leading to higher adherence to exercise interventions.26 E-DATs can facilitate monitoring of exercise progress for cancer survivors in real time, providing them with virtual feedback to enhance motivation and address potential exercise barriers.26–28 Additional benefits of E-DATs include objective data collection, patient-tailored (or precision) interventions, and in some cases, ability to communicate virtually with healthcare providers regarding symptoms, exercise experience, or questions.
Use of E-DAT behavioral interventions is a rapidly expanding area of research and practice27–29 but has only recently been applied to cancer survivors.30,31 To improve understanding of this emerging field, we conducted a systematic review to summarize findings from randomized controlled trials (RCTs) of E-DATs in cancer survivors. The primary aim of this review was to evaluate retention and adherence rates to E-DATs. The secondary aim was to assess the effects of E-DATs on activity level, body composition, objective fitness outcomes, HRQoL, self-reported symptoms, and biomarker data.
The authors would like to acknowledge Daniel Castillo for his assistance in performing the literature search and Susan Rosenthal for her editorial assistance.
Disclosures: The authors have disclosed that they have not received any financial considerations from any person or organization to support the preparation, analysis, results, or discussion of this article.
Funding: This work was supported by the NCI, including funds from NCORP (UG1CA189961), NCORP supplement (U10CA037420), and R25CA102618.
Previous Presentation: This research was presented as a poster at the 2018 ASCO Cancer Survivorship Symposium; February 16–17, 2018; Orlando, Florida.
See JNCCN.org for supplemental online content.
Denlinger CS, Sanft T, Baker KS et al.. Survivorship, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2017;15:1140–1163.
de Moor JS, Mariotto AB, Parry C et al.. Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epidemiol Biomarkers Prev 2013;22:561–570.
Stein KD, Syrjala KL, Andrykowski MA. Physical and psychological long-term and late effects of cancer. Cancer 2008;112:2577–2592.
Loh KP, Pandya C, Zittel J et al.. Associations of sleep disturbance with physical function and cognition in older adults with cancer. Support Care Cancer 2017;25:3161–3169.
Kleckner IR, Dunne RF, Asare M et al.. Exercise for toxicity management in cancer—a narrative review. Oncol Hematol Rev 2018;14:28–37.
Knols R, Aaronson NK, Uebelhart D et al.. Physical exercise in cancer patients during and after medical treatment: a systematic review of randomized and controlled clinical trials. J Clin Oncol 2005;23:3830–3842.
Strasser B, Steindorf K, Wiskemann J et al.. Impact of resistance training in cancer survivors: a meta-analysis. Med Sci Sports Exerc 2013;45:2080–2090.
Mustian KM, Alfano CM, Heckler C et al.. Comparison of pharmaceutical, psychological, and exercise treatments for cancer-related fatigue: a meta-analysis. JAMA Oncol 2017;3:961–968.
Stout NL, Baima J, Swisher AK et al.. A systematic review of exercise systematic reviews in the cancer literature (2005-2017). PM R 2017;9:S347–384.
Kim TH, Chang JS, Kong ID. Effects of exercise training on physical fitness and biomarker levels in breast cancer survivors. J Lifestyle Med 2017;7:55–62.
Sweegers MG, Altenburg TM, Chinapaw MJ et al.. Which exercise prescriptions improve quality of life and physical function in patients with cancer during and following treatment? A systematic review and meta-analysis of randomised controlled trials. Br J Sports Med 2018;52:505–513.
- Search Google Scholar
- Export Citation
. Sweegers MG Altenburg TM Chinapaw MJ Which exercise prescriptions improve quality of life and physical function in patients with cancer during and following treatment? A systematic review and meta-analysis of randomised controlled trials. Br J Sports Med 2018; 52: 505– 513.
Kushi LH, Doyle C, McCullough M et al.. American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin 2012;62:30–67.
Kampshoff CS, Jansen F, van Mechelen W et al.. Determinants of exercise adherence and maintenance among cancer survivors: a systematic review. Int J Behav Nutr Phys Act 2014;11:80.
Kampshoff CS, van Mechelen W, Schep G et al.. Participation in and adherence to physical exercise after completion of primary cancer treatment. Int J Behav Nutr Phys Act 2016;13:100.
Husebo AM, Karlsen B, Allan H et al.. Factors perceived to influence exercise adherence in women with breast cancer participating in an exercise programme during adjuvant chemotherapy: a focus group study. J Clin Nurs 2015;24:500–510.
Daley AJ, Crank H, Mutrie N et al.. Determinants of adherence to exercise in women treated for breast cancer. Eur J Oncol Nurs 2007;11:392–399.
McAuley E, Mullen SP, Szabo AN et al.. Self-regulatory processes and exercise adherence in older adults: executive function and self-efficacy effects. Am J Prev Med 2011;41:284–290.
Neupert SD, Lachman ME, Whitbourne SB. Exercise self-efficacy and control beliefs: effects on exercise behavior after an exercise intervention for older adults. J Aging Phys Act 2009;17:1–16.
Larson JL, Covey MK, Kapella MC et al.. Self-efficacy enhancing intervention increases light physical activity in people with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2014;9:1081–1090.
Edmunds J, Ntoumanis N, Duda JL. Adherence and well-being in overweight and obese patients referred to an exercise on prescription scheme: a self-determination theory perspective. Psychol Sport Exerc 2007;8:722–740.
Rajati F, Sadeghi M, Feizi A et al.. Self-efficacy strategies to improve exercise in patients with heart failure: a systematic review. ARYA Atheroscler 2014;10:319–333.
Alharbi M, Gallagher R, Neubeck L et al.. Exercise barriers and the relationship to self-efficacy for exercise over 12 months of a lifestyle-change program for people with heart disease and/or diabetes. Eur J Cardiovasc Nurs 2017;16:309–317.
Ormel HL, van der Schoot GG, Sluiter WJ et al.. Predictors of adherence to exercise interventions during and after cancer treatment: a systematic review. Psychooncology 2018;27:713–724.
Evidence Generation Guide for Apps and Wearables Developers: Study Designs Including Applied Examples. Final Report. Available at: http://www.yhec.co.uk/yhec-content/uploads/2017/03/YHEC-Study-Designs-28.03.17.pdf. Accessed December 1, 2018.
Kuijpers W, Groen WG, Aaronson NK, van Harten WH. A systematic review of web-based interventions for patient empowerment and physical activity in chronic diseases: relevance for cancer survivors. J Med Internet Res 2013;15:e37.
Bort-Roig J, Gilson ND, Puig-Ribera A et al.. Measuring and influencing physical activity with smartphone technology: a systematic review. Sports Med 2014;44:671–686.
Bantum EO, Albright CL, White KK et al.. Surviving and thriving with cancer using a Web-based health behavior change intervention: randomized controlled trial. J Med Internet Res 2014;16:e54.
Haggerty AF, Huepenbecker S, Sarwer DB et al.. The use of novel technology-based weight loss interventions for obese women with endometrial hyperplasia and cancer. Gynecol Oncol 2016;140:239–244.
Marshall G. The Story of Fitbit: How a Wooden Box Became a $4 Billion Company. Available at: https://www.wareable.com/fitbit/youre-fitbit-and-you-know-it-how-a-wooden-box-became-a-dollar-4-billion-company. Accessed December 2, 2018.
LaPorte RE, Montoye HJ, Caspersen CJ. Assessment of physical activity in epidemiologic research: problems and prospects. Public Health Rep 1985;100:131–146.
Vallance JK, Courneya KS, Plotnikoff RC et al.. Randomized controlled trial of the effects of print materials and step pedometers on physical activity and quality of life in breast cancer survivors. J Clin Oncol 2007;25:2352–2359.
Vallance JK, Courneya KS, Plotnikoff RC et al.. Analyzing theoretical mechanisms of physical activity behavior change in breast cancer survivors: results from the activity promotion (ACTION) trial. Ann Behav Med 2008;35:150–158.
Irwin ML, Cadmus L, Alvarez-Reeves M et al.. Recruiting and retaining breast cancer survivors into a randomized controlled exercise trial: the Yale Exercise and Survivorship Study. Cancer 2008;112:2593–2606.
Jones SB, Thomas GA, Hesselsweet SD et al.. Effect of exercise on markers of inflammation in breast cancer survivors: the Yale exercise and survivorship study. Cancer Prev Res (Phila) 2013;6:109–118.
Haines TP, Sinnamon P, Wetzig NG et al.. Multimodal exercise improves quality of life of women being treated for breast cancer, but at what cost? Randomized trial with economic evaluation. Breast Cancer Res Treat 2010;124:163–175.
Backman M, Wengstrom Y, Johansson B et al.. A randomized pilot study with daily walking during adjuvant chemotherapy for patients with breast and colorectal cancer. Acta Oncol 2014;53:510–520.
Mayo NE, Moriello C, Scott SC et al.. Pedometer-facilitated walking intervention shows promising effectiveness for reducing cancer fatigue: a pilot randomized trial. Clin Rehabil 2014;28:1198–1209.
James EL, Stacey FG, Chapman K et al.. Impact of a nutrition and physical activity intervention (ENRICH: Exercise and Nutrition Routine Improving Cancer Health) on health behaviors of cancer survivors and carers: a pragmatic randomized controlled trial. BMC Cancer 2015;15:710.
- Search Google Scholar
- Export Citation
. James EL Stacey FG Chapman K Impact of a nutrition and physical activity intervention (ENRICH: Exercise and Nutrition Routine Improving Cancer Health) on health behaviors of cancer survivors and carers: a pragmatic randomized controlled trial. BMC Cancer 2015; 15: 710.
Park JH, Lee J, Oh M et al.. The effect of oncologists' exercise recommendations on the level of exercise and quality of life in survivors of breast and colorectal cancer: a randomized controlled trial. Cancer 2015;121:2740–2748.
Gokal K, Wallis D, Ahmed S et al.. Effects of a self-managed home-based walking intervention on psychosocial health outcomes for breast cancer patients receiving chemotherapy: a randomised controlled trial. Support Care Cancer 2016;24:1139–1166.
Jarden M, Moller T, Christensen KB et al.. Multimodal intervention integrated into the clinical management of acute leukemia improves physical function and quality of life during consolidation chemotherapy: a randomized trial ‘PACE-AL’. Haematologica 2016;101:e316–319.
- Search Google Scholar
- Export Citation
. Jarden M Moller T Christensen KB Multimodal intervention integrated into the clinical management of acute leukemia improves physical function and quality of life during consolidation chemotherapy: a randomized trial ‘PACE-AL’. Haematologica 2016; 101: e316– 319.
Sajid S, Dale W, Mustian K et al.. Novel physical activity interventions for older patients with prostate cancer on hormone therapy: a pilot randomized study. J Geriatr Oncol 2016;7:71–80.
Schwenk M, Grewal GS, Holloway D et al.. Interactive sensor-based balance training in older cancer patients with chemotherapy-induced peripheral neuropathy: a randomized controlled trial. Gerontology 2016;62:553–563.
Uhm KE, Yoo JS, Chung SH et al.. Effects of exercise intervention in breast cancer patients: is mobile health (mHealth) with pedometer more effective than conventional program using brochure? Breast Cancer Res Treat 2017;161:443–452.
Hills S. Nintendo Readies for “Wii Fit” Launch. Available at: https://www.reuters.com/article/us-nintendo-wiifit/nintendo-readies-for-wii-fit-launch-idUSN2152363320080222. Accessed December 2, 2018.
Eapen ZJ, Turakhia MP, McConnell MV et al.. Defining a mobile health roadmap for cardiovascular health and disease. J Am Heart Assoc 2016;5:pii: e003119.
Walker SR, Roashan R. Wearable Technology: The Small Revolution is Making Big Waves. Available at: https://technology.ihs.com/api/binary/526640. Accessed December 2, 2018.
Santa Mina D, Alibhai SM, Matthew AG et al.. Exercise in clinical cancer care: a call to action and program development description. Curr Oncol 2012;19:e136–144.
Yardley L, Bishop FL, Beyer N et al.. Older people's views of falls-prevention interventions in six European countries. Gerontologist 2006;46:650–660.
Brawley LR, Rejeski WJ, King AC. Promoting physical activity for older adults: the challenges for changing behavior. Am J Prev Med 2003;25:172–183.
Karvinen KH, Courneya KS, Venner P et al.. Exercise programming and counseling preferences in bladder cancer survivors: a population-based study. J Cancer Surviv 2007;1:27–34.
Cobiac LJ, Vos T, Barendregt JJ. Cost-effectiveness of interventions to promote physical activity: a modelling study. PLoS Med 2009;6:e1000110.
Albrecht TA, Taylor AG. Physical activity in patients with advanced-stage cancer: a systematic review of the literature. Clin J Oncol Nurs 2012;16:293–300.
Valenzuela T, Okubo Y, Woodbury A et al.. Adherence to technology-based exercise programs in older adults: a systematic review. J Geriatr Phys Ther 2018;41:49–61.
Hawley-Hague H, Horne M, Skelton D et al.. Review of how we should define (and measure) adherence in studies examining older adults' participation in exercise classes. BMJ Open 2016;6:e011560.
Jones LW, Eves ND, Haykowsky M et al.. Exercise intolerance in cancer and the role of exercise therapy to reverse dysfunction. Lancet Oncol 2009;10:598–605.
Jones LW, Liu Q, Armstrong GT et al.. Exercise and risk of major cardiovascular events in adult survivors of childhood Hodgkin lymphoma: a report from the childhood cancer survivor study. J Clin Oncol 2014;32:3643–3650.
Brown JC, Harhay MO, Harhay MN. Physical function as a prognostic biomarker among cancer survivors. Br J Cancer 2015;112:194–198.
Li T, Wei S, Shi Y et al.. The dose-response effect of physical activity on cancer mortality: findings from 71 prospective cohort studies. Br J Sports Med 2016;50:339–345.
Mishra SI, Scherer RW, Snyder C et al.. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev 2012:CD008465.
Ferrer RA, Huedo-Medina TB, Johnson BT et al.. Exercise interventions for cancer survivors: a meta-analysis of quality of life outcomes. Ann Behav Med 2011;41:32–47.
Hitz F, Ribi K, Li Q et al.. Predictors of satisfaction with treatment decision, decision-making preferences, and main treatment goals in patients with advanced cancer. Support Care Cancer 2013;21:3085–3093.
Asadi-Lari M, Tamburini M, Gray D. Patients' needs, satisfaction, and health related quality of life: towards a comprehensive model. Health Qual Life Outcomes 2004;2:32.
Gleeson M, Bishop NC, Stensel DJ et al.. The anti-inflammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease. Nat Rev Immunol 2011;11:607–615.
Case MA, Burwick HA, Volpp KG et al.. Accuracy of smartphone applications and wearable devices for tracking physical activity data. JAMA 2015;313:625–626.
Fortuin J, Salie F, Abdullahi LH et al.. The impact of mHealth interventions on health systems: a systematic review protocol. Syst Rev 2016;5:200.
Iribarren SJ, Cato K, Falzon L et al.. What is the economic evidence for mHealth? A systematic review of economic evaluations of mHealth solutions. Plos One 2017;12:e0170581.