Factors influencing physical activity in individuals with head and neck cancer: a scoping review.

STRENGTHS AND LIMITATIONS OF THIS STUDY

This scoping review presents a comprehensive overview based on quantitative and qualitative findings.

Expert knowledge was compiled by including recommendations and views from healthcare professionals and researchers.

A broad concept of different physical activity (PA) modalities included everyday activities and targeted PA such as exercise.

No quality assessment of the included studies was performed.

Background and rationale

Head and neck cancer (HNC) ranks as the seventh most prevalent cancer type worldwide with its incidence growing. 1 The primary risk factors for HNC include persistent tobacco and alcohol consumption, as well as infection with the human papillomavirus for pharyngeal cancer. 1 Most HNCs are diagnosed in stage III or IV, prompting extensive treatments involving a combination of surgery and radiation therapy, potentially complemented by chemotherapy. 2 Individuals diagnosed with HNC face a more than twofold risk for disabilities compared with those with other cancer diagnoses 3 and exhibit higher levels of frailty. 4 HNC treatments can substantially increase morbidity due to treatment toxicity. Functional deficits related to swallowing and speaking, along with disfigurement following surgery and radiation, can significantly impact the quality of life for individuals with HNC. 5 6

Physical activity (PA) is defined as ‘any bodily movement produced by skeletal muscles that result in energy expenditure’. 7 Everyday PA are all activities during leisure time, at work or during transport to get from one place to another. 8 This includes walking, climbing stairs, gardening, doing household chores and many other activities during daily life. Exercise is a targeted form of PA, that is purposeful and organised, characterised by repetition and designed to enhance or preserve physical fitness and overall health. 7 A growing body of evidence demonstrates the positive effects of PA and exercise in individuals affected by cancer. Regular PA and exercise can improve many treatment side effects, enhance overall health and quality of life. 9 11 Accordingly, guidelines advise to integrate PA into the treatment and survivorship care of individuals with cancer. 12 15 Nevertheless, several factors hinder the implementation of these recommendations, including personal, social, environmental and health-related factors. Commonly cited barriers encompass treatment side effects, time constraints or inadequate information. 16 17 Depenbusch et al 18 demonstrated that 30%–60% of individuals diagnosed with various cancer types encounter structural barriers to PA.

Research findings indicate positive effects of PA and exercise interventions on the overall health status and quality of life among patients with HNC. 19 21 Samuel et al 20 showed that patients with HNC undergoing chemoradiotherapy could achieve a significant improvement of their functional capacity, their quality of life and could prevent worsening of fatigue when following an intensive structured in-patient exercise rehabilitation programme for 7 weeks followed by a home-based exercise programme for 4 weeks. An observational longitudinal study by Huang et al 22 showed that higher activity levels were associated with better quality of life. Nevertheless, individuals with HNC are especially susceptible to low activity levels or sedentary behaviour. 23 24 Already prior to diagnosis, this group appears to have low activity levels. 23 Barriers to being physically active include physical or psychological factors such as treatment-related side effects that interfere with PA, lack of knowledge and poor motivation. 25 Research exploring the contextual and influencing factors of PA in patients with HNC remains limited. Recent reviews have primarily focused on identifying barriers to and facilitators for engaging in PA. 25 26 A more comprehensive understanding of this topic is essential to inform the development of programmes and interventions aimed at promoting PA in individuals with HNC in the future. The research questions for our scoping review were as follows: (1) What factors are associated with PA in patients diagnosed with HNC? (2) What are known barriers to and facilitators for PA in this population? (3) What beliefs, perceptions and views do patients diagnosed with HNC express regarding PA? (4) What views and recommendations do healthcare professionals and researchers have for promoting PA in this group?

Methods

We conducted a scoping review to address our research questions by exploring the existing knowledge and prior research on factors that influence PA in patients with HNC. 27 Our methods were based on Arksey and O’Malley’s framework, 28 best practice guidance by Peters et al 29 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline extension for scoping reviews. 30

Search strategy and eligibility criteria

We adopted a broad search strategy for three concepts: (1) HNC, (2) influencing factors including barriers, facilitators, beliefs, perceptions and views and (3) PA, exercise or physical training. A medical librarian reviewed our search strategy. One researcher (MS) used the EBSCO host interface to execute the search in the CINHAL, Medline and APA PsychINFO databases, and then searched in Embase, Scopus and the Cochrane Library. The full search strategy is available in online supplemental S1 . MS hand searched the reference lists of all included articles for additional relevant publications and added these for full-text screening if they met inclusion criteria. To locate full-text articles for study protocols, poster abstracts or study register entries, we conducted searches using the author’s name and study title on Google Scholar or the website of the authors’ affiliation. If unsuccessful, we contacted the authors. We last searched on 5 July 2023.

Publications were eligible for inclusion if they focused on patients with HNC or incorporated a subgroup analysis specific to this population. In addition, the concept of PA had to be analysed in the publication, either including everyday PA or targeted PA such as exercise. Finally, the publication had to address influencing factors for PA. These factors included barriers, facilitators, beliefs, perceptions or views. We excluded studies on thyroid or oesophageal cancer 1 and full texts that were not in English or German. We placed no limit on study design or publication date.

Study selection

We imported our search results into the review tool Covidence. 31 The screening of titles and abstracts was conducted independently by 2 reviewers (MS and a research assistent), who screened a common set of 20 titles and 10 abstracts to align their judgments. Full-text screening was performed independently by three reviewers (MB, MS and RE), who collectively screened the first five full-text articles to calibrate inclusion decisions for the scoping review. The reviewers subsequently convened three more times to discuss and resolve any conflicts that arose during the screening process.

Data extraction and charting

MS extracted data about study characteristics such as design, study aim and population. To address our research questions, we extracted data on influencing factors such as barriers, facilitators, beliefs, views and perceptions regarding PA for people affected by HNC. Further, we extracted views and recommendations of healthcare professionals and researchers in the field. The data were sorted by personal, social, environmental and health-related factors and characteristics that influenced PA. For studies containing quantitative data, we charted their results descriptively. In cases involving qualitative data, we performed a basic content analysis 32 by deductively allocating concepts or characteristics into categories. 33 Healthcare professionals’ or researchers’ suggestions were extracted either from qualitative study results or the discussion sections of the studies.

Patient and public involvement

For the design of the scoping review, no patient or public involvement was applied. This review builds the basis for a subsequent project, in which people affected by HNC and their family members will be interviewed to explore how a PA promotion programme should be designed to best fit their needs.

Results

Literature search results

Our literature search retrieved 1351 publications. After removing duplicates, we screened 650 studies following our predefined screening protocol ( figure 1 ). Through the screening of references during or after the full-text review, we identified and added 18 additional studies; we contacted one research team to obtain unpublished data. We ultimately reviewed the full text of 79 studies and included 19 in our review.

Characteristics of included studies

All included studies were published within the last 15 years, with nearly two-thirds (n=12) published within the last five years. Geographically, the studies were predominantly conducted in North America and Europe, with the majority (five) conducted in the USA, followed by Canada, the UK and the Netherlands (four each). Germany and Sweden each contributed one study. There were 11 quantitative studies, 34 44 six qualitative studies 45 50 and two mixed methods studies. 51 52 The majority (n=13) had a cross-sectional design, reporting outcomes derived from surveys or standardised questionnaires. Some included additional data from medical chart review. Three publications were feasibility studies, and one was a controlled pilot trial. Qualitative and mixed-method studies were primarily based on individual interviews, with one exception utilising focus group interviews (see table 1 ). For more details on the included studies, see online supplemental S2 .

Description of study participants

Patients before, during and shortly after medical treatment for HNC were included, 35 38 43 47 50 52 as well as individuals within the first year after treatment, or during long-term care. 3436 37 39 42 44 One study 47 included healthcare professionals. The quantitative studies analysed data from 1530 participants; qualitative studies analysed data from 122 participants ( table 1 ).

Factors associated with PA

Seven publications analysed associations between a variety of factors and PA levels, interest and intention for PA. 3435 37 39 41 52 These factors included personal and health-related characteristics of the person, but also their attitude, perception and motivation.

Personal factors associated with PA levels included age, 34 39 educational level, 41 marital status, 34 alcohol consumption, 35 having worries about harm, 52 being committed to or motivated for PA, 52 setting goals or perceiving barriers, enjoying PA or being self-efficient. 35 37 Health-related factors included cancer stage or type, sleep quality, 34 having comorbidities, 34 35 39 weight loss 39 or having a feeding tube. 34 Intention and interest for PA were influenced by the person’s age, health condition 40 and attitude towards PA 39 40 or exercise history 39 The type and direction of the associations are presented in table 2 .

Barriers to and facilitators for PA

Of the 19 studies included in this analysis, 13 reported barriers to PA, 3738 40 44 46 48 while seven reported factors that facilitate engagement in PA. 4045 48 52

The prevailing barriers to PA were primarily associated with health, treatment or environmental factors, as outlined in table 3 . Fatigue or low energy ranked highest in health-related reasons for inactivity or decisions not to exercise. 4041 44 48 52 Pain, both in general, 40 41 48 50 52 and specifically in the head, neck and shoulder region, 44 49 as well as eating and feeding difficulties, 3740 41 49 51 hindered PA. Environmental barriers to PA were primarily related to work and family responsibilities. 4243 49 51 Personal barriers to PA were mainly due to lack of time, 4243 49 51 motivation, interest and intention. 37 42 51 52 Some participants mentioned laziness, 48 49 and some feared worsening their condition. 41 48

Factors facilitating PA included an individuals’ perception and experience of the health benefits, as well as support from their social network ( table 3 ). The most frequently stated facilitators of PA engagement were feeling mentally and physically better, 47 5052 and experiencing or perceiving general health benefits. 4048 50 PA was also enhanced by a sense of power and control and the positive feelings that resulted from PA. 39 45 50 52 Emotional and practical support from an individual’s network, including partners and family members, was a major social factor that facilitated PA. 45 48 52

Patients’ beliefs, views and perceptions on PA

Individuals with HNC acknowledged the benefits of PA and expressed the need for more information on how to become physically active. Study participants reported that PA contributed to their well-being, both physically and mentally, 47 52 providing them with a sense of personal empowerment. 45 They were motivated to increase their PA levels to improve their physical and mental health, as well as their fitness levels. 48 They suggested that they would benefit from more education and information about recovering from the side effects of cancer treatment. 47 Exercising in a group was found to have the advantage of facilitating the exchange of information and discussion about experiences. 51 Patients did not associate their health behaviour with morbidity, and felt that the information they received to change their health behaviour was too focused on prevention rather than function. 46

Participants suggested that a tailored programme to promote PA should consider personal preferences, address barriers and enhance facilitators. 47 Additionally, they highlighted that PA promotion programmes should be supervised by experts to minimise risk of injury and to enhance adherence and enjoyment. 35 Participants also emphasised that surgeons should support and encourage PA. 47 49

Healthcare professionals’ and researchers’ views and recommendations on PA in people with HNC

With the exception of three studies, 37 38 44 all of the included publications stated expert views and recommendations on PA promotion. From these data, five overarching themes emerged (see table 4 ). They included: addressing symptoms and barriers; providing information and education; addressing behaviour, attitude and intention; provision of support within the healthcare system and suggestions about PA intervention delivery.

Many study teams recommended regular screening and adequate addressing of physical and psychological symptoms and patients’ perceived barriers. 3435 40 41 46 48 50 52 Tailored and individualised approaches were suggested to help people with a HNC diagnosis to increase their PA levels. 40 43 47 49 51 To increase the self-efficacy and competence of people with HNC, standard care should include patient education about the benefits of PA and how to overcome barriers from the time of diagnosis onwards. 4143 47 49

Healthcare professionals should also be educated to increase their awareness of the benefits of PA for patients. They should take an active role in motivating and facilitating PA to enhance patients’ recovery. 41 47 49 Individuals diagnosed with HNC tend to overestimate their activity level and may require special guidance and referrals to exercise specialists to help them prioritise PA and change their behaviour. 48 52 PA interventions should be integrated into the HNC care pathway as usual care 40 47 50 and should be promoted by all members of the healthcare team. 42 47 49

The type and mode of delivery of PA interventions or programmes should be tailored to an individual’s abilities, preferences and goals. 40 43 47 49 50 Furthermore, PA programmes should be flexible and take place at locations convenient for the patient. 50 51

Discussion

The objective of our scoping review was to provide an overview of the known factors that influence PA in people diagnosed with HNC, such as barriers, facilitators, beliefs, views and perceptions experienced by people being affected, as well as to compile views and recommendations from experts in the field. A variety of personal, environmental, social and health-related factors can influence PA. Patients and experts suggest that PA should be integrated into the HNC treatment pathway. This should include providing information and education on how to manage symptoms and overcome barriers. Furthermore, PA promotion should actively support individual behaviour change, facilitating motivation and intention to increase PA levels.

Factors associated with PA

This review found an association between individual characteristics and PA levels. Personal and health-related factors were specifically linked to lower PA levels. This is consistent with a previous study which reported that lower PA levels were associated with educational level, number of comorbidities and tumour stage among newly diagnosed patients with HNC. 23

Barriers to and facilitators for PA

Most of the included publications cite health- and treatment-related barriers as the most important barrier to PA. When comparing cancer types, individuals with HNC seem to be the most vulnerable group for having comorbidities that hinder PA. Gildea et al 53 showed that two-thirds of patients with HNC stated comorbidities as a barrier to PA, whereas this percentage was lower for all other examined cancer types including multiple myeloma (50%), prostate cancer (25%), colorectal cancer (12%) and breast cancer (4%). The most common health-related barrier to PA in our review is fatigue. Fatigue, a prevalent issue for individuals with cancer, can be alleviated through exercise and PA. 54 Sharp et al 55 demonstrated that almost one-third of patients with HNC experienced clinically significant fatigue symptoms during the first year after diagnosis, with the peak occurring four months after diagnosis, affecting almost 45% of patients. International guidelines 56 57 recommend counselling for PA and exercise promotion. Further investigation into the potential of enhancing PA engagement through fatigue screening during and after the treatment phase is warranted. In our review, pain and eating problems are also among the most reported health-related barriers. According to a systematic review by van den Beuken et al , 58 patients with HNC had a higher prevalence of pain compared with those with other cancer types. Patients with oral cancer were found to be particularly susceptible to pain, with almost 70% affected. 59 Swallowing, eating and feeding difficulties are also highly prevalent and specific to HNC, placing a significant burden on affected individuals, 60 and feeding tubes may be required. 61 This area of concern has also been underscored in our review. The prolonged times required for eating or being fed through an enteral tube can contribute to the most common personal reason people with HNC cite for being inactive: lack of time. The shortage of time was frequently identified as a primary barrier to PA in various cancer types 26 and seems to be most prominent in the phase after treatment. 53

Support from their social network is a major factor in facilitating PA for individuals affected by HNC as seen in our result. This is in line with research on other cancer types which also describe the importance of social support and guidance as a main facilitator for PA. 53 62 Therefore, interventions promoting PA should actively involve and encourage family members or other individuals from patients’ networks to support PA. Osazuwa-Peters et al 63 demonstrated that being married reduced mortality rates for people with HNC by one-third, highlighting the significant positive impact of having a partner. Given that not every person with HNC has a close network or a significant other for support, these individuals may require additional support. Family and network involvement should be subject of further research, as it has the potential to improve the situation. 64

Patients’ beliefs, views and perceptions on PA

This scoping review confirms that patients diagnosed with HNC are motivated to increase their PA to enhance their physical and mental health. Our findings align with studies indicating that PA is linked to an improved health status and an improved sense of control and satisfaction for patients with HNC, as well as those with other cancer types. 17 25 26

Our results suggest that facilitating behaviour change should be further explored and targeted in tailored interventions for individuals with HNC. Some patients with HNC may not intend to change their PA behaviour because they believe that they are sufficiently active or overestimate their personal PA levels. 48 52 Low health literacy or lack of knowledge about the effects of health behaviours may hinder PA uptake; nearly 50% of patients with HNC were found to be insufficiently health literate in the sample analysed by Clarke et al , 65 which has also been associated with being less self-efficient. Educating patients with HNC about the benefits of PA and providing access to interventions to promote self-efficacy, a precursor for behaviour change, may increase PA levels in this population. 46 48

Healthcare professionals’ and researchers’ views and recommendations on PA in people with HNC

Tailored interventions or PA programmes align with patients’ needs in reducing barriers to integrate PA into their lives, as demonstrated in the results of this review. Additionally, healthcare professionals are aware of PA benefits and the importance of screening risk factors for low PA levels during the HNC treatment pathway. However, there are currently no corresponding recommendations on how this should be implemented in clinical practise; this should be explored in more detail in the future.

The findings of this review suggest that PA should be an integral part of the treatment pathway for patients with HNC. In contrast to this recommendation, the clinical practice guideline for HNC of the National Comprehensive Cancer Network 66 in the USA and the guidelines of the European Society of Medical Oncology (ESMO) 67 have not yet incorporated this recommendation. Conversely, the American Cancer Society’s HNC survivor guidelines 68 proposes PA for a later period during the cancer care continuum, asserting that primary care clinicians should recommend PA. It should be considered to actively promote PA during the treatment phase, providing clinicians with the opportunity for ‘teachable moments’ to assist patients with HNC in integrating PA into their daily activities. 69 70

Our review confirms that patients with HNC require customised programmes, consistent with the recommendations for PA promotion for patients affected by various cancer types. 17 18 26 53 However, it remains still unclear which intervention components are essential and when they should be delivered during the cancer journey to best address patients’ needs. This scoping review affirms that healthcare professionals and researchers are convinced that more information and education on PA benefits should be provided to patients and professionals. Haussmann et al 71 confirm that in-depth PA counselling is necessary to enhance PA levels in patients with cancer, but is rarely delivered to them.

Implications for further research

There are several topics that require further investigation to advance the implementation of PA promotion within the care continuum of individuals with HNC.

Understanding how, when and by whom screening for relevant symptoms and barriers related to PA should be conducted.

Developing tailored information and effective education for individuals affected by HNC and for healthcare professionals involved in their care.

Improving understanding of the motivation for, intention to and behaviour change towards increased PA in individuals with HNC.

Strengths and limitations

A strength of this scoping review lies in its extensive examination of factors influencing PA in people with HNC. By incorporating views and recommendations from healthcare professionals and researchers, valuable expert knowledge is compiled. The review consolidate evidence on PA in patients diagnosed with HNC, affirming findings on barriers and facilitators from previous research. 25 26 Moreover, the review suggests open questions for future research to advance PA promotion in people affected by HNC.

The results of this scoping review should be interpreted cautiously because the concept of PA was defined broadly, and the context of PA was heterogeneous. The included studies investigated everyday PA, analysed exercise interventions within a study setting during treatment or analysed PA after treatment was completed. Our goal was to compile knowledge on influencing factors and recommendations from the literature and to suggest future exploration. Owing to the heterogeneous nature of the data sources and the different sample sizes of the studies, objective quantification of the various factors was not feasible. Instead, an approximation of the importance of a particular factor was only provided by indicating the frequency of citations. The results of this review are not generalisable since no quality assessment for the included studies was executed. Quality assessment is not usually part of the methodology of a scoping review, which rather seeks to provide a comprehensive overview of the diverse existing evidence on a particular topic. 28

Conclusion

Personal, social, environmental and health-related factors have an influence on PA in patients with HNC. These factors encompass personal characteristics such as age and comorbidities, as well as factors such as attitude, interest and motivation. Treatment side effects and the overall health condition of individuals place the most important barriers to PA, whereas perceived benefits and support from the persons’ network act as facilitators to PA. Patients with HNC express a desire for personalised information and programmes tailored to their needs. Experts suggest that support and education should be provided within the healthcare system to overcome barriers and promote PA by addressing behaviour, attitude and intention. Further research is necessary to understand how to best encourage patients’ PA participation and how and when to provide the necessary information and support to overcome potential PA barriers.

supplementary material

Acknowledgements

Special thanks to Dr Martina A Gosteli, Liason Librarian Medicine, University Library, University of Zurich for her support with the search strategy, Natalie Meister, physiotherapist MSc at Cantonal Hospital Winterthur for her help with title and abstract screening and Dr Kali Tal, lecturer academic writing, University Library of Bern, for providing feedback on the paper.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online ( https://doi.org/10.1136/bmjopen-2023-083852 ).

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent for publication: Not applicable.

Ethics approval: Not applicable.

Data availability free text: Additional materials with the detailed search strategy and more detailed overview of included studies are available as online supplemental S1 and S2. Further material can be provided on request.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

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Data availability statement

The data sheet on the extracted data is available on reasonable request from the study authors.