1. Introduction
In 2019 it was estimated that about 3.5 million Italians (5.3% of the entire population) are living after a cancer diagnosis [
1]. Improvements in medical treatments have led to a substantial increase in the proportion of cancer patients with death rates similar to those of the general Italian population [
2].
Cancer and its treatments are associated with various side effects that negatively affect the patient’s quality of life for a long time after the conclusion of therapies [
3,
4]. There is growing evidence that in cancer patients (especially breast, colon and prostate) [
5,
6,
7] an active lifestyle is associated with a lower risk of recurrence and mortality. Physical activity (PA) refers to any bodily movement produced by skeletal muscles that requires energy expenditure [
8]. Exercise is defined as a subcategory of PA, consisting of structured, planned and repetitive movement [
8]. Exercise was shown to be safe and feasible in oncological settings [
9] and several studies found that exercise improved patients’ quality of life during [
10,
11] and after treatment [
11]. Positive effects of exercise include increasing cardiorespiratory fitness [
12] and muscular strength [
13], and improvement in body composition [
13]. Additionally, exercise helped regulate several side effects of cancer treatment, such as fatigue [
14], and nausea [
15], and improved the psychological status, for instance, reducing levels of anxiety and depression [
16].
Despite the benefits related to PA and exercise, a large percentage of cancer patients from 25% to 84% are not sufficiently active [
17,
18,
19] and the level of exercise has been seen to decrease after cancer diagnosis [
20]. A multitude of factors influence the participation of the general population in exercise programs (e.g., lack of time, cost, logistic difficulties, etc.) [
21]. Cancer patients face further obstacles on account of their condition (e.g., cancer-related fatigue, muscle weakness, nausea, sleep disorders) [
22,
23]. To develop a successful exercise intervention, cancer patients’ barriers and preferences must be considered, allowing them to pick the activities they perceive as beneficial and enjoyable [
23,
24,
25,
26]. International studies investigated the preferences and determinants of exercise levels in cancer patients and survivors [
18,
27,
28,
29,
30,
31,
32,
33], but data on the Italian population are lacking. Furthermore, cultural differences in this area might be significant. In order to overcome this information gap the STIP-ON (Sustainable training in pazienti oncologici) survey was designed with the following aims: (i) To understand the size of the problem, i.e., to calculate the prevalence of insufficient exercise among cancer patients; (ii) to analyze the patients’ characteristics associated with insufficient exercise; (iii) to analyze the patients’ characteristics associated with their motivation/willingness to take part in a future intervention program on exercise; (iv) to describe patients’ preferences about exercise.
The rationale of the study is that understanding patients’ preferences and barriers to physical activity will make it easier for them to participate successfully in a future intervention study to improve their physical fitness.
4. Discussion
The STIP-ON survey found that only 7% of cancer patients do enough physical exercise. Previous studies reported the percentage of cancer patients with adequate exercise levels, between 16–85% [
17]. Considering the impact of physical inactivity on the quantity [
5,
6,
7] and quality [
10,
11] of life in cancer patients this is an alarming result.
Roughly 80% of patients were willing to start an exercise program designed for cancer patients. Previous studies reported similar results, finding that the majority of bladder [
39], non-Hodgkin’s lymphoma [
29], prostate [
27], head and neck [
31], endometrial [
28], ovarian [
30] and breast [
27] cancer survivors were interested in an exercise program. This is important because it supports the cancer patients’ desire for an exercise service.
Several socio-demographic characteristics were associated with the willingness to participate in an exercise program. Willingness decreased with age, also in fully adjusted models, and this was to be expected given the growing difficulties and comorbidities due to aging. Age has been associated with low adherence to exercise in cancer patients in various studies [
30,
40]. What is interesting is that, even among the older patients, more than two-thirds said they might be interested in taking part in an exercise program. Women were more willing to participate than men. That was found in all models, even after adjustment for medical and socio-demographic variables. That women cancer patients adhere better than men in exercise programs is suggested by an intervention study in rectal cancer patients [
40] although a systematic review evaluating the predictors of adherence to exercise interventions during cancer treatment suggested that adherence was best among men [
41]. Better-educated patients were more willing to participate. This was reported in other studies, too [
30,
42], and a likely explanation is well-educated people’s greater awareness and knowledge of the benefits of exercise. It is interesting that economic security was not related to the willingness to participate, and that too was suggested by other studies [
40]. This lack of association might be the result of two concomitant and opposing phenomena: those who have less financial availability willingly accept a free offer to exercise; the same poorer people, however, may have less desire to exercise because they are less motivated or because they do manual work. Patients who reported higher frequencies of sweat-inducing activity were more willing to participate in an exercise program that those less frequently reporting it. This can be summed up with the Italian saying: “it rains where it’s already wet”; in other words, those who are most motivated are those who would need it less. No similar results were found in the literature, but a possible explanation is that those who have already done more physical exercise perceive the benefits better and are therefore more ready to improve or increase their level [
43]. Chemotherapy was inversely associated with the willingness to participate. There is one study that found no relation between cancer treatment and adherence in high-intensity and low-to-moderate-intensity exercises [
42]; other studies found chemotherapy [
41] and its side effects [
22] were associated with low adherence to physical exercise programs. One explanation for these contradictory results may be that chemotherapy is a generic term that includes different drugs and various possible side effects. There were no differences in willingness to participate based on other medical variables, and this is consistent with previous work on this topic [
30].
Regarding the preferred source of exercise instruction, the oncologist was the preferred person to deliver instructions in the present survey and this is not in line with the current standard of care. Previous investigations reported an exercise expert (kinesiologist) as the favorite [
17]. Findings from the present survey may be related to the lack of exercise specialists for patients at the Verona Hospital Oncology Unit. The trusting relationship between the patient and the oncologist built up during the cancer journey is another likely explanation. Less than half of oncologists promote exercise with their patients [
44]. Barriers that interfere with exercise promotion by oncologists were identified as lack of time, limited access to an exercise specialist/program and lack of knowledge about exercise in cancer [
45]. However, educational sessions about exercise in cancer patients and caregivers, specific education materials (leaflets, brochures, posters, etc.) and/or a kinesiologist as part of the clinical team are recognized factors to help promote exercise [
45].
Social support plays a role in exercise program compliance [
46]. In the oncological setting, social support enhances emotional well-being [
47] and is related to PA engagement [
48]. The present results are in line with this: 55% of patients preferred exercise with others (cancer patients, relatives, friends); about 87% expressed interest in having a helper, i.e., a person to help and motivate them with the exercise, identifying various subjects: the spouse or other relatives, or exercise specialists. Social support from different helpers has been seen to be effective for behavior change [
49]: family, friends, peers, exercise specialists, healthcare providers, and other influential subjects might be the key figures to support compliance and the maintenance of exercise over time [
50].
Although in previous studies there was a marked preference for a home-based program [
17,
27,
28,
30,
39], in this study similar percentages of patients preferred exercising outside, or in an adapted exercise fitness center, or at home. This suggests that providing different program options would boost compliance for exercise interventions. To reinforce this assumption, subjects were asked what they would choose out of three exercise options (individually with a program to follow at home/individually in a gym with a kinesiologist/in a group class with a kinesiologist/none of these). More than 90% indicated their preference among these options.
The majority of STIP-ON participants preferred a supervised exercise program. This finding contrasts with studies on bladder [
39], head and neck [
31], prostate and breast [
27] cancer, but is in line with other investigations on mixed [
51], lung [
52] and endometrial [
28] cancers. One explanation might be related to the patients’ health condition: cancer-related treatments affect normal physical function and influence daily activities, hence the need for supervision from a qualified figure to avoid adverse effects. Moreover, supervised exercise intervention may give additional benefits for cancer patients. A recent metanalysis including a total of 4519 patients with mixed cancer types evaluated the effect of exercise on quality of life and physical function; it found twice the effect size for supervised compared to unsupervised training [
53].
In line with previous studies [
27,
28,
30,
31,
39,
51], a substantial proportion of patients indicated walking as their favorite activity, in winter and summer. Walking programs have been effective to manage treatment side effects and improve physical functions in cancer populations [
54,
55]. Walking is relatively safe, flexible and easy as it does not require special skills [
56]. Moreover, walking can be done in different environmental situations, is accessible and appropriate in groups of different age, sex, ethnicity, education or income levels, and does not require expensive equipment. Walking is also known to reduce social barriers among people of different socio-economics status [
57].
Contrary to other reports [
27,
28,
31,
51,
52], the present study indicated the preferred exercise intensity as mild. Exercise guidelines for cancer patients suggest they should engage in at least moderate exercise [
58]. Mild intensity could be the choice to start an exercise program, especially with physically ‘deconditioned’ people, and should be gradually increased to moderate and vigorous intensity. Several reviews show moderate-to-vigorous but not mild exercise intensity is effective in managing cancer side effects, and improves physical function [
14,
59].
In light of this evidence, the present findings highlight the need to inform cancer patients and their caregivers about the safety of moderate and vigorous intensities exercise. Patients’ exercise levels were related to their educational level, type of treatment and body fatness. Several studies have investigated the determinants and triggers of exercise behaviors in patients, but with inconsistent findings [
60,
61,
62].
This appears to be the first study investigating the determinants of exercise preferences in Italian cancer patients before they were involved in exercise intervention programs. The study results provide useful data for planning future exercise programs. The self-reported QEX permitted the collection of a large amount of data and was quickly administered, without much burden on respondents, or costs. Another point of strength is the collection of information about why individuals did not wish to take part in the study.
Limitations of the study need to be noted: the QEX information was self-reported and therefore open to several sources of bias. The QEX was filled and returned anonymously, so social desirability bias (for instance, patients may exaggerate their physical activity so as not to ‘disappoint’ the researcher) is less likely. The information leaflet given to patients at recruitment provides minimal information presenting the study but does not contain any recommendations/guidelines. However, just having provided information might have influenced the replies. Another potential source of error is selection bias: cancer patients who agreed to participate in the survey may be individuals more interested in exercise. To ensure a representative sample of patients, a random sample of outpatients was selected. Finally, the questionnaire does not serve to classify exercise adherence according to the new ACSM [
58] guidelines for cancer patients. These guidelines were released in October 2019, after the QEX had been administered to the study sample of patients [
58]. Nevertheless, the QEX classifies patients according to the previous ACSM guidelines [
37]. This allows us to compare patients’ exercise levels with the studies that have been reported so far. Classification of the LSI according to the ACSM guidelines for cancer patients [
37] allows a full comparison of study finding with the majority of other studies in the field. Nevertheless, this classification may have artificially inflated the percentage of participants who reported insufficient physical activity. The QEX does not collect information about participants’ pre-diagnosis exercise and physical activity and that limit its ability to explore associations with other possible determinants of current exercise behavior. The patients in STIP-ON were sampled to be representative of those attending the Verona oncology clinic (and not the full total of patients). Therefore, although more severe patients with severe comorbidities are likely to have been excluded, patients’ responses may also have been influenced by other comorbidities that were not investigated by the QEX.
Information from this survey is clinically relevant and may help in designing personalized interventions so cancer patients will achieve sufficient exercise/PA. Here are a few examples: (i) Since about 90% of participants said they wanted or needed a helper during the program, a targeted intervention program should include specific activities (and support) for helpers patients will nominate; (ii) Because about 30% of respondents said they prefer to exercise with other patients, exercise classes specifically for them and “learning from peers” social occasions should be organized; (iii) The majority of patients were insufficiently active and preferred mild exercise or slow walking. So as not to leave anyone behind, for those who are not able to engage in moderate exercise, a mild flexible entry program should be offered according the patient’s condition and preferences and then progress slowly towards higher-intensity exercise.