Predictors of Exercise Adherence in Asian Cancer Patients in a Community Based Cancer Rehabilitation Center: An Exploratory Study

doi:10.21203/rs.3.rs-8338466/v1

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Research Article

Predictors of Exercise Adherence in Asian Cancer Patients in a Community Based Cancer Rehabilitation Center: An Exploratory Study

https://doi.org/10.21203/rs.3.rs-8338466/v1

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Background

Physical exercise is a vital component of cancer rehabilitation, with demonstrated improvements in cancer health-related outcomes including anxiety, depression, fatigue, physical function and health-related QoL, yet global participation remains low. In Singapore, uptake of community cancer rehabilitation is limited despite high prevalence of treatment-related impairments. This study aims to establish the knowledge, attitudes and beliefs of Asian cancer patients towards exercise in a community-based community rehabilitation program as well as the clinical characteristics associated with adequate physical exercise levels.

Methods

A cross-sectional study was conducted among adults (≥ 21 years) enrolled in the Singapore Cancer Society Rehabilitation Centre between December 2021 and March 2023. Clinical data, comorbidity burden, cancer characteristics, and treatment history were collected from medical records. Assessments included the Distress Thermometer (DT), Brief Illness Perception Questionnaire (Brief IPQ), and modified Bandura’s Exercise Self-Efficacy (ESE) scale. Patient-reported personal and societal barriers to exercise were recorded (Yes/No). Adequate exercise was defined as ≥ 150 min/week of moderate aerobic activity and ≥ 2 days/week of resistance training. Logistic regression analyses were performed to identify factors associated with achieving aerobic exercise recommendations.

Results

Of 132 analysed participants, only 29.5% met recommended aerobic exercise levels and 9.1% met resistance training recommendations. The three most common cancer diagnoses amongst the participants were breast (53.8%), gastrointestinal (11.4%) and gynecological (7.6%) cancers. Clinically significant distress (DT ≥ 5) was present in 41.9%. Univariate analyses showed that moderate comorbidity (OR = 4.299 ; p = 0.034) and genitourinary cancers (OR = 18.667 ; p = 0.010) were positive predictors of adequate exercise. Negative predictors of adequate exercise included female gender (OR = 0.284 ; p = 0.004), prior chemotherapy (OR = 0.429 ; p = 0.046), and lower self-efficacy (OR = 0.840 ; p = < 0.001).

Conclusions

Exercise adherence among Asian cancer survivors in community rehabilitation is low. Our findings highlight the urgent need for targeted, context-specific interventions within Asian community cancer survivorship programs. Future efforts should focus on gender-specific programming, enhancing exercise self-efficacy and early outreach and screening.

Cancer Rehabilitation

Community Rehabilitation

Rehabilitation

Exercise

With advances in the diagnosis and management of cancer, an increasing number of patients with cancer today can expect an improved survival rate through early detection and treatment¹. Unfortunately, despite advances in cancer care, anticancer therapeutics still cause significant acute and long-term physical morbidity, including but not limited to, cancer-related fatigue, pain, neuropathies, cardiopulmonary limitations and balance and gait dysfunction^2–5. Unfortunately, despite the high prevalence of these physical impairments, few patients receive appropriate exercise-based rehabilitation. Even in developed countries, rehabilitation rates for readily remediable cancer related physical impairments are reported to be as low as 1–2%⁶.

Physical exercise is a vital component of cancer rehabilitation, with demonstrated improvements in cancer health-related outcomes including anxiety, depression, fatigue, physical function and health-related QoL^7–11. As a result, numerous guidelines recommend that cancer patients should avoid inactivity and engage in consistent physical exercise¹². The majority of guidelines recommend that cancer patients aim for at least 150 minutes of moderate-intensity aerobic exercise per week, along with resistance training ≥ 2 days per week for all major muscle groups, tailored to their specific diagnosis, treatment, and physical condition^12–14.

Key challenges in the local adoption of exercise-based rehabilitation services likely exist, which may include lack of awareness, passive engagement of community partners, poor health literacy, and worries about the risks of physical activity after a cancer diagnosis. These can form barriers to patients being referred to or attend exercise programs in outpatient cancer rehabilitation centers.

Hence, it is important to identify cancer patients at risk of being non-adherent to exercise recommendations, as this will aid in identifying at-risk patients and guide best practices to increase exercise adoption and adherence in this vulnerable population. As such, this study aims to establish the knowledge, attitudes and beliefs of Asian cancer patients towards exercise in a community-based community rehabilitation program as well as the clinical characteristics associated with adequate physical exercise levels.

Participants

This was a cross sectional study which recruited cancer patients enrolled in the Singapore Cancer Society Rehabilitation Centre between the periods of December 2021 to March 2023. This is a national community-based rehabilitation center, which receives referrals for cancer patients from clinical specialists or primary care physicians from any healthcare institution after they had started or completed their acute oncological treatment, e.g. surgery, chemotherapy, radiotherapy, hormonal therapy, immunotherapy, targeted therapy, or any combination of the aforementioned treatment.

The referral criteria were cancer patients who were in the pre, active and post treatment phase, in medically stable condition and experienced symptoms that require rehabilitative support. The community cancer rehabilitation program provides comprehensive exercise-based rehabilitation services with a physician-led multidisciplinary team, which includes physiotherapists, occupational therapists, nutritionists and medical social workers.

Inclusion and exclusion criteria

Eligibility included patients who are ≥ 21 years old and enrolled in the cancer rehabilitation program. Patients were excluded if they had terminally ill conditions, had major psychiatric illness or had cognitive or communication difficulties. This clinical study was performed in accordance with the principles of the Declaration of Helsinki and written informed consent was obtained from all the participants in this study. Ethical approval was obtained from the local institutional review board, Agency for Integrated Care (2021-007).

Assessment

Collection of data and assessments with questionnaires were performed during the enrollment of participants into the Singapore Cancer Society Rehabilitation Centre’s cancer rehabilitation program.

The clinical and pathological data were collected through chart reviews, patient interviews and questionnaires. Data collected from patient electronic records included age, gender, ethnicity, comorbidities, type and stage of cancer and type of cancer treatment. Comorbidities were classified using the Charlson Comorbidity Index (CCI). CCI classes were defined as mild with scores of 1 to 2 points, moderate with scores of 3 to 4 points and severe with scores of ≥ 5 points^15,16.

The primary outcome measure studied was the achievement of the American Cancer Society’s guideline of adequate aerobic exercise, defined as ≥ 150minutes/week of moderate intensity aerobic exercise on average¹², based on the Physical Activity Vital Sign tool¹⁷. We also studied the adequacy of resistance exercise involving major muscle groups¹⁸ per week, which was defined by the American Cancer Society as performing resistance exercise ≥ 2 days/week on average¹².

The Distress Thermometer (DT) tool was utilized in our study. It is a single-item self-reported measure of distress. Patients were asked to grade their distress in the past week on an 11-point visual analog scale ranging from 0 (no distress) to 10 (extreme distress). A DT score of ≥ 5 was used as a cut-off indicating a clinically significant level of distress^3,19.

The Brief Illness Perception Questionnaire (Brief IPQ) is a 9 item self-reported measure used to rapidly assess the cognitive and emotional representation of the participant’s illness based on a 11-point rating scale ranging from 0 (no illness perception) to 10 (greatest illness perception)²⁰. These representations of illness include the consequences, timeline, personal control, treatment control, identity coherence, concern, emotional response and causes. Research has demonstrated the importance of illness representations to patient behavior²¹.

Our study also utilized a modified version of Bandura’s Exercise Self-Efficacy (ESE) scale to assess ESE^22,23. The scale is a 9 item self-reported scale to measure how confident participants are with regards to carrying out regular physical activities and exercise recommendations in diverse conditions and circumstances. Responses are based on a 4-point rating scale ranging from 1 (very likely) to 4 (very unlikely). A total score from the 9 items would be calculated and range from 9 to 36. A lower total score of the 9 items would indicate higher ESE, while the highest score of 36 would represent the least efficacy.

Common patient and societal barriers to exercise in cancer patients were also explored in our study. Patients barriers explored include participants' perception of whether they feel too weakened from their cancer therapy to participate in exercise, feel fatigued and have issues with sleep, being uninterested in an exercise rehabilitation program, being not physically active before their cancer diagnosis, having a fear of adverse events during the exercise rehabilitation program and not thinking that an exercise rehabilitation program will have a positive impact on their QoL²⁴. Societal barriers include high transport fees, daily stress, lack of time, and cost of such an exercise rehabilitation program²⁴. Responses from participants were collected using a binary (Yes/No) format.

Statistical analysis

Descriptive statistics of demographic and clinical variables were presented based on normality, as determined by the Shapiro Wilk test. Continuous variables with normal distribution were presented as mean and standard deviation, while those with non-normally distributed data were presented as median and 25–75th percentiles. Logistic regression analysis was used to determine univariate and multivariable associations with meeting moderate aerobic exercise requirements. The following variables were subjected to univariate analysis investigating their relationship with meeting requirements for aerobic exercise: age, gender, ethnicity, cancer type, cancer stage, treatment modalities (e.g. surgery, chemotherapy, radiotherapy, hormonal therapy, immunotherapy, targeted therapy), DT, illness beliefs, ESE, patient and societal barriers. Covariates in the unadjusted analyses were then included in the subsequent multivariable regression model. Statistical analyses were performed using Jamovi Version 2.7.9.0. All estimates were reported along with the 95% confidence interval (CI) and a P value of less than 0.05 was considered statistically significant for a 2-tailed test.

A total of 133 cancer patients were recruited from the outpatient cancer rehabilitation clinic. However, 1 patient was excluded from data analysis due to incomplete data collection. (Table 1.) The majority of the patients were 61 to 70 years old (31.1%) and 51 to 60 years old (27.3%). Females made up the most of the recruited participants (78.0%), with the majority of the participants being Chinese (82.6%). The three most common cancer diagnoses amongst the participants were breast (53.8%), gastrointestinal (11.4%) and gynecological (7.6%) cancers. A significant minority of participants had metastatic disease (27.3%). Most patients had previous surgery (77.3%) and chemotherapy (75.8%), while a minority received radiotherapy (47.7%), hormone therapy (30.3%), and targeted therapy (3.0%). The majority of patients had severe (46.32%) comorbidity as measured with CCI.

Table 1

Clinical characteristics of study participants
Characteristics	n (%)
Age
Age 40 and below	11 (8.3)
Age 41 to 50	21 (15.9)
Age 51 to 60	36 (27.3)
Age 61 to 70	41 (31.1)
Age 71 and above	23 (17.4)
Gender
Male	29 ( 22.0)
Female	103 (78.0)
Ethnicity
Chinese	109 (82.6)
Malay	15 (11.4)
Indian	4 (3.0)
Others	4 (3.0)
Distress Thermometer (DT) Score
< 5	75 (58.1)
≥ 5	54 (41.9)
Charlson Comorbidity Index (CCI)
1 to 2 points (Mild comorbidity)	25 (18.9)
3 to 4 points (Moderate comorbidity)	46 (34.8)
≥ 5 points (Severe comorbidity)	61 (46.2)
Cancer Type
Breast	71 (53.8)
Gastrointestinal tract	15 (11.4)
Gynaecological	10 (7.6)
Lung	9 (6.8)
Haematological	9 (6.8)
Head and neck	7 (5.3)
Genitourinary (Bladder/Prostate)	6 (4.5)
Hepato-pancreato-biliary	2 (1.5)
Other Ca or unknown primary	2 (1.5)
Brain	1 (0.8)
Stage of Cancer
Non-Metastatic	96 (72.7)
Metastatic	36 (27.3)
Treatment Received
Surgery	102 (77.3)
Chemotherapy	100 (75.8)
Radiotherapy	63 (47.7)
Hormone therapy	40 (30.3)
Targeted therapy	4 (3.0)
Exercise Levels At Time of Recruitment
Adequate aerobic exercise ^a	39 (29.5)
Adequate resistance exercise ^b	12 (9.1)
Note.
^a Adequate aerobic exercise : > 150 Minutes/week of moderate intensity aerobic exercise
^b Adequate resistance exercise : > 2 Days/week of resistance exercise of major muscle groups

Table 1.

Table 2.

Table 2

Illness perception of study participants
	Median (IQR)
How much does the side effects of cancer and treatment affect your life?	6.0 (4.0–8.0)
How long do you think the side effects of cancer and treatment will continue?	6.0 (4.0–8.0)
How much control do you feel you have over the side effects of cancer and treatment?	5.0 (3.0–7.0)
How much do you think a cancer rehabilitation program can help the side effects of cancer and treatment?	7.0 (5.0–8.0)
How much do you experience the side effects of cancer and treatment?	6.0 (4.0–8.0)
How concerned are you about the side effects of cancer and treatment?	7.0 (5.0–8.0)
How well do you feel you understand the side effects of cancer and treatment?	6.0 (5.0–8.0)
How much does the side effects of cancer and treatment affect you emotionally?	6.0 (5.0–8.0)
Note. Scores from the Brief Illness Perception Questionnaire (Brief IPQ). Higher scores indicate greater illness perception.

There were 54 (41.9%) patients who experienced clinically significant distress (DT scores ≥ 5). The scores of the Brief IPQ and barriers to exercise are presented in Tables 2. and 3. The most common personal barrier to an exercise-based rehabilitation program was problems with fatigue and sleep (27.3%). The most common social barrier was the impression that an exercise-based rehabilitation program was too expensive (31.1%). The median total score of the ESE scale was 22.5 (IQR: 18.8–26.0) (Table 4.). With regard to exercise, only a minority of participants were achieving at least 150 minutes of moderate intensity exercise per week (29.5%), with only 9.1% of participants achieving at least 2 days of resistance exercise per week.

Table 3.

Table 3

Patient and societal barriers to exercise and rehabilitation
	n (%)
Personal Barriers
I feel weakened due to my cancer therapy.	16 (12.1)
I feel fatigued and have issues with sleep.	36 (27.3)
I am not interested in an exercise program.	6 (4.5)
I was not physically active before my cancer diagnosis.	21 (15.9)
I have a fear of adverse events.	8 (6.1)
I do not think an exercise program will have a positive impact on my quality of life.	5 (3.8)
Societal Barriers
High costs of transport fees.	9 (6.8)
Stressful daily life.	15 (11.4)
Lack of time for exercise.	39 (29.5)
Rehabilitation is too expensive.	41 (31.1)
Note.

Table 4.

Table 4

Exercise self-efficacy of study participants
	Median (IQR)
Exercise regularly (3 times a week, for 20 minutes).	2.0 (1.0–2.0)
Exercise when you are feeling tired.	2.0 (2.0–3.0)
Exercise when you are feeling under pressure to get things done.	2.0 (2.0–3.0)
Exercise when you are feeling down or depressed.	2.0 (3.0–3.0)
Exercise when you have too much work to do at home.	2.0 (3.0–3.0)
Exercise when there are other more interesting things to do.	2.0 (2.0–3.0)
Exercise when your family or friends do not provide any kind of support.	2.0 (2.0–3.0)
Exercise when you do not really feel like it.	2.0 (3.0–3.0)
Exercise when you are away from home (e.g., traveling, visiting, on vacation).	2.0 (3.0–3.0)
Total Score ^a	22.5 (18.8–26.0)
Note. Score from the modified version of Bandura’s Exercise Self-Efficacy (ESE) scale
^a Sum of scores from the 9 items of the modified version of Bandura’s Exercise Self-Efficacy (ESE) scale with the highest possible score of 36. The lower the total score, the higher the ESE the participant has.

Results of univariate analyses revealed that the significant positive factors for achieving adequate aerobic exercise were having moderate comorbidity (OR = 4.299 ; 95% CI = 1.118–16.527 ; p = 0.034) and genitourinary cancers (OR = 18.667 ; 95% CI = 2.025–172.104 ; p = 0.010). Significant negative predictive factors for achieving adequate aerobic exercise were a female gender (OR = 0.284 ; 95% CI = 0.120–0.670 ; p = 0.004), previous treatment with chemotherapy (OR = 0.429 ; 95% CI = 0.186–0.985 ; p = 0.046), higher ESE (OR = 0.840 ; 95% CI = 0.772–0.913 ; p = < 0.001), the greater the experience of side effects of cancer treatment (OR = 0.842 ; 95% CI = 0.718–0.987 ; p = 0.034), the greater the emotional impact of the side effects of cancer treatment (OR = 0.821 ; 95% CI = 0.699–0.964 ; p = 0.016), the greater the perception that the side effects of cancer treatment has affected life (OR = 0.834 ; 95% CI = 0.717–0.970 ; p = 0.019) and the perception that the side effects of cancer treatment will continue (OR = 0.863 ; 95% CI = 0.748–0.996 ; p = 0.044). However, other factors such as ethnicity, DT score, presence of metastatic disease, previous surgery, previous radiotherapy, previous hormone therapy, previous targeted therapy, personal and societal barriers were not significant factors for meeting the adequate aerobic exercise target. (Table 5.)

Table 5

Univariate logistic regression for meeting adequate aerobic exercise levels
Characteristics
	Odds Ratio	95% CI	P Value
Age
Age 40 and below	1.000
Age 41 to 50	0.281	(0.039–2.010)	0.206
Age 51 to 60	1.173	(0.260–5.280)	0.835
Age 61 to 70	1.238	(0.281–5.440)	0.777
Age 71 and above	2.051	(0.430–9.780)	0.367
Gender
Male	1.000
Female	0.284	(0.120–0.670)	0.004
Ethnicity
Chinese	1.000
Malay	0.158	(0.019–1.247)	0.080
Indian	2.206	(0.298–16.322)	0.438
Others	2.206	(0.298–16.322)	0.438
Distress Thermometer (DT) Score
≤ 4	1.000
≥ 5	0.634	(0.289) − 1.393)	0.257
Charlson Comorbidity Index (CCI)	1.092	(0.939–1.271)	0.254
1 to 2 points (Mild comorbidity)	1.000
3 to 4 points (Moderate comorbidity)	4.299	(1.118–16.527)	0.034
≥ 5 points (Severe comorbidity)	3.317	(0.884–12.448)	0.076
Cancer type
Breast	1.000
Gastrointestinal tract	2.489	(0.765–8.098)	0.130
Gynaecological	0.933	(0.179–4.864)	0.935
Lung	1.867	(0.417–8.353)	0.414
Haematological	2.987	(0.713–12.517)	0.135
Head and neck	2.800	(0.564–13.893)	0.208
Genitourinary (Bladder/Prostate)	18.667	(2.025–172.104)	0.010
Hepato-pancreato-biliary	2.39 × 10⁻⁷	(0.0 – ∞)	0.993
Other Ca or unknown primary	3.733	(0.220–63.249)	0.362
Brain	2.39 × 10⁻⁷	(0.0 – ∞)	0.995
Stage of Cancer
Non-Metastatic	1.000
Metastatic	0.889	(0.380–2.078)	0.785
Treatment Received
Surgery	0.447	(0.192–1.040)	0.063
Chemotherapy	0.429	(0.186–0.985)	0.046
Radiotherapy	1.224	(0.579–2.588)	0.597
Hormone therapy	0.600	(0.254–1.419)	0.245
Targeted therapy	0.789	(0.079–7.833)	0.840
Illness Perception
How much does the side effects of cancer and treatment affect your life?	0.834	(0.717–0.970)	0.019
How long do you think the side effects of cancer and treatment will continue?	0.863	(0.748–0.996)	0.044
How much control do you feel you have over the side effects of cancer and treatment?	0.922	(0.893–1.070)	0.293
How much do you think a cancer rehabilitation program can help the side effects of cancer and treatment?	1.116	(0.900–1.382)	0.316
How much do you experience the side effects of cancer and treatment?	0.842	(0.718–0.987)	0.034
How concerned are you about the side effects of cancer and treatment?	0.877	(0.763–1.010)	0.066
How well do you feel you understand the side effects of cancer and treatment?	0.894	(0.830–1.180)	0.894
How much does the side effects of cancer and treatment affect you emotionally?	0.821	(0.699–0.964)	0.016
Personal Barriers
I feel weakened due to my cancer therapy.	0.513	(0.138–1.911)	0.320
I feel fatigued and have issues with sleep.	0.599	(0.245–1.466)	0.262
I am not interested in an exercise program.	1.43 × 10⁻⁷	(0.0 – ∞)	0.987
I was not physically active before my cancer diagnosis.	0.708	(0.240–2.089)	0.531
I have a fear of adverse events.	0.323	(0.038–2.720)	0.299
I do not think an exercise program will have a positive impact on my quality of life.	1.44 × 10⁻⁷	(0.0 – ∞)	0.988
Societal barriers
High costs of transport fees.	0.664	(0.132–3.349)	0.620
Stressful daily life.	0.852	(0.254–2.859)	0.795
Lack of time for exercise.	0.761	(0.328–1.766)	0.525
Rehabilitation is too expensive.	0.690	(0.298–1.595)	0.385
Exercise Self-Efficacy (ESE)
Exercise regularly (3 times a week, for 20 minutes).	0.234	(0.118–0.466)	< 0.001
Exercise when you are feeling tired.	0.377	(0.225–0.632)	< 0.001
Exercise when you are feeling under pressure to get things done.	0.386	(0.233–0.640)	< 0.001
Exercise when you are feeling down or depressed.	0.482	(0.301–0.773)	0.002
Exercise when you have too much work to do at home.	0.304	(0.176–0.525)	< 0.001
Exercise when there are other more interesting things to do.	0.527	(0.324–0.859)	0.010
Exercise when your family or friends do not provide any kind of support.	0.457	(0.280–0.745)	0.002
Exercise when you do not really feel like it.	0.396	(0.230–0.681)	< 0.001
Exercise when you are away from home (e.g., traveling, visiting, on vacation).	0.868	(0.565–1.330)	0.520
Total Score ^a	0.840	(0.772–0.913)	< 0.001
Note.
^a Sum of scores from the 9 items of the modified version of Bandura’s Exercise Self-Efficacy (ESE) scale with the highest possible score of 36. The lower the total score, the higher the ESE the participant has.

Table 5.

Upon performing multivariate analysis (Table 6.), significant negative factors for achieving adequate aerobic exercise was being female (OR = 0.300 ; 95% CI = 0.103–0.874 ; p = < 0.027) and lower ESE (OR = 0.841 ; 95% CI = 0.767–0.922 ; p = < 0.001)

Table 6

Multivariate logistic regression for meeting adequate aerobic exercise levels
Characteristics
	Odds Ratio	95% CI	P Value
Gender
Male	1.000
Female	0.300	(0.103–0.874)	0.027
Charlson Comorbidity Index (CCI)
1 to 2 points (Mild comorbidity)	1.000
3 to 4 points (Moderate comorbidity)	3.001	(0.625–14.419)	0.170
≥ 5 points (Severe comorbidity)	1.773	(0.381–8.246)	0.465
Treatment received
Chemotherapy	0.470	(0.178–1.236)	0.126
Illness Perception
How much does the side effects of cancer and treatment affect your life?	1.063	(0.772–1.464)	0.708
How long do you think the side effects of cancer and treatment will continue?	0.891	(0.713–1.114)	0.311
How much do you experience the side effects of cancer and treatment?	1.069	(0.815–1.400)	0.631
How much does the side effects of cancer and treatment affect you emotionally?	0.854	(0.638–1.144)	0.290
Exercise Self-Efficacy (ESE)
Total Score ^a	0.841	(0.767–0.922)	< 0.001
Note.
^a Sum of scores from the 9 items of the modified version of Bandura’s Exercise Self-Efficacy (ESE) scale with the highest possible score of 36. The lower the total score, the higher the ESE the participant has.

Table 6.

This study characterizes the exercise levels, knowledge, attitudes, and barriers among Asian cancer patients enrolled in a community-based rehabilitation program in Singapore. Increased exercise and physical activity can confer a multitude of health benefits to cancer patients²⁵. These health benefits also extend to patients with metastatic disease, making exercise interventions an integral part of every cancer survivorship program^11,26–28. Despite the documented benefits of increased physical exercise in cancer patients, our study found a low prevalence (29.5%) of cancer patients fulfilling the recommended amount of aerobic exercise per week with a smaller proportion (9.1%) meeting the recommended amount of resistance exercise per week. This is not dissimilar to other cancer studies, where it is estimated that only between 17% and 58% of cancer patients adhere to physical activity guidelines²⁹. Our analysis also revealed that being female and poorer exercise self-efficacy were associated with patients not meeting the recommended aerobic exercise requirements.

Female cancer patients, in comparison with male cancer patients, were more likely to not fulfil the recommended aerobic exercise requirements in our study. This is despite females making up the majority (78.0%) of our total study population and breast cancer being the most common cancer subtype (53.8%). However, this finding reflects overall population trends that illustrate males being more physically active than females³⁰. Similar results were noted in prior studies of cancer patients, which reported male cancer patients were more likely to meet recommended levels of physical activity compared to their female counterparts^31,32. Psychological barriers, physical barriers and societal barriers may pose barriers to exercise in females³³. For example, changes in physical appearance due to surgery (e.g. mastectomy, abdominal surgery) or treatment (e.g. radiotherapy) can make female patients feel self-conscious or embarrassed about exercising in public spaces such as gyms or swimming pools. This may be compounded by difficulty in acquiring proper-fitting athletic wear. Incisional discomfort at mastectomy surgical scar sites may also prevent the wearing of appropriate athletic clothes and limit exercise³⁴. Asian female cancer patients may still be expected by families to fulfil various roles, such as being caregivers, mothers, wives, limiting them from participating in adequate exercise^35–37. This is particularly relevant in the Asian context where traditional familial roles may place a higher burden of caregiving and domestic duties on female survivors. Female patients may also have the perception that the home chores that they perform are appropriate substitutions to actual exercise³⁸.

Our study also revealed increased levels of illness perception within the cancer patients in the community, with median scores of the components of the Brief IPQ ranging from 5 to 7. A high proportion of our participants reported that the side effects of cancer and treatment had considerably affected their lives and resulted in increased levels of distress. We postulated that these may have been attributed to the side effects and complications of chemotherapy, which was also found to be a negative predictive factor for achieving the recommended levels of exercise in our study. The association between chemotherapy induced side effects and reduced level of physical activity is well reported in the medical literature^28,39. Chemotherapy treatment is known to result in a myriad of different side effects that may discourage cancer patients from exercising. These side effects include anemia, blisters, neuropathy, fatigue, gastrointestinal issues, myelo-suppression, pain, and motor weakness³⁹. Neuropathy related balance problems can lead to fear of falling and avoidance of exercise in public spaces without supervision. In a study by Toohey K et al, about one-third of participants reported that physical activity was not a priority when chemotherapy side effects predominated³⁴. However, physical activity is beneficial in addressing side effects of chemotherapy including pain, fatigue, and neuropathy, which would otherwise lower physical activity levels^40–42. This may reflect the relative lack of awareness amongst cancer patients regarding the benefits of exercise in addressing the side effects of chemotherapy and the potential lack of resources allocated in the community setting. This is evidenced by a local study in Singapore where only 46.1% of cancer patients reported receiving some form of exercise guidance from healthcare professionals following cancer diagnosis⁴¹.

Personal and societal barriers to exercises cited by our study participants included the lack of time (29.5%), cost issues (31.1%) and fatigue (27.3%). This is also supported by an earlier local study by Chan A et al⁴¹, where adverse effects from cancer treatment (52.0%), lack of time (20.6%) and costs (15.7%) have also been cited by cancer patients as barriers to physical activity⁴³. Cancer treatment combined with the lack of adequate funding for community survivorship care can result in considerable financial strain on patients^44,45, and this may limit access to relevant exercise interventions^43,46.

The study also revealed that cancer patients with moderate comorbidity levels (CCI score of 3 to 4) were significantly more likely to fulfill exercise recommendations compared to those with mild comorbidity levels (CCI score 1 to 2). In contrast to our findings, the literature reports an inverse relationship between CCI scores and physical activity levels, with higher CCI scores associated with lower physical activity levels, reduced physical fitness and sedentary lifestyles^47–50. We hypothesize that patients with comorbidities may have been in frequent contact with healthcare providers prior to their cancer diagnosis and may have received some form of structured rehabilitation prior to study recruitment. These patients may already have been compliant with exercise advice from prior structured rehabilitation programs, such as those in established cardiac or pulmonary rehabilitation programs^51,52. Thus, these results emphasize the need to place adequate attention and resources into cancer patients with lower levels of comorbidity, who may have been missed by existing structured rehabilitation pathways, and may not have been aware of the importance of rehabilitation programs.

The study also reported that genitourinary cancers were a positive predictor for meeting aerobic exercise recommendations. There is strong evidence showing that exercise has a positive effect in patients with genitourinary cancers in terms of quality of life and physical fitness^53–55. However, prior studies have shown that the compliance in meeting exercise recommendations remains low in prostate cancer patients. Retrospective studies have reported a low prevalence of 34% of prostate cancer patients meeting recommendations⁵⁶, which is also similarly low in metastatic prostate cancer patients⁵⁷. Our results may be a reflection of well-established local support programs, potentially driven by specific disease-centric initiatives, that regularly link genitourinary cancer patients to support and exercise-related programs^58–61.

Cancer patients with higher ESE tend to view exercise as a useful strategy in managing cancer-related side effects and demonstrate stronger intrinsic motivation and adherence to exercise. In contrast, patients with lower ESE show less initiative to use exercise to address cancer-related side effects, report poorer adherence to exercise, and experience lower levels of social support⁶². Our study also concurred with previous findings where low ESE (higher ESE scores) were predictive of not achieving recommended levels of exercise. Self-efficacy refers to a person’s confidence in successfully executing coping behaviors necessary to cope with cancer diagnosis and problems associated with it and its related treatment^22,63. Self-efficacy varies depending on the context and the nature of the specific task and has become a target of many self-management interventions⁶⁴. A higher self-efficacy in cancer patients has been shown to be associated with better wellbeing, QoL, and reduced physical and psychological burden^65–68. ESE plays an important role in determining whether cancer patients initiate and adhere to exercise recommendations. Personal barriers such as cancer-related fatigue⁶² and structural barriers, such as the lack of information or suitable exercise facilities⁶⁹ can influence ESE. Therefore, strategies to enhance self-management and overcome these barriers to exercise must be integrated into all cancer survivorship programs⁷⁰.

There are several limitations that require highlighting. Firstly, the exploratory and cross-sectional nature of this study limits the generalizability and interpretation of results. Secondly, we were also unable to determine the demographics, clinical factors and exercise recommendation adherence of patients who were not screened as part of our outpatient cancer rehabilitation program. Thirdly, we were unable to obtain data pertaining to physical factors (e.g. baseline function prior to cancer diagnosis, frailty status at the time of study enrollment), socioeconomic factors (e.g. household income, mode of transport, presence of children, presence of a dedicated caregiver, social support), psychological factors (e.g. anxiety, depression) and treatment factors (e.g. details of chemotherapy regime), which may have influenced physical activity. Lastly, physical activity levels were all self-reported without objective verification, running the risk of misclassification.

We found a low prevalence of adherence to recommended exercise guidelines among cancer patients in our study. Our findings highlight the urgent need for targeted, context-specific interventions within Asian community cancer survivorship programs. Future efforts should focus on gender-specific programming, enhancing exercise self-efficacy and early outreach and screening. By addressing these key barriers and tailoring strategies to clinical and psychological risk factors, community-based cancer rehabilitation programs can significantly improve exercise adherence and, consequently, optimize health outcomes for cancer survivors.

Charlson Comorbidity Index (CCI)

Distress Thermometer (DT)

Brief Illness Perception Questionnaire (Brief IPQ)

Exercise Self-Efficacy (ESE)

Confidence interval (CI)

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Agency for Integrated Care (2021-007)

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare no conflict of interest.

Funding

This research received no external funding.

Author Contributions

MRJT and LW were responsible for the conception and design of the study.

MRJT and LW were responsible for the acquisition of data for this manuscript.

LYCT and MRJT were responsible for the interpretation of data and drafting of the manuscript.

MRJT, LW, JQG and CJW have reviewed and edited the manuscript.

All authors have read and agreed to the published version of the manuscript.

Acknowledgments

The authors wish to thank the Singapore Cancer Society (SCS) for their administrative support and research assistance as well as for granting permission for research involving the patients undergoing rehabilitation at their center.

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Predictors of Exercise Adherence in Asian Cancer Patients in a Community Based Cancer Rehabilitation Center: An Exploratory Study

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