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Abstract
Objective To synthesise qualitative literature on (1) the perceptions of patients with cancer of participating in an exercise intervention while undergoing chemotherapy and (2) to inform and guide professionals in oncology and haematology practice.
Design A qualitative meta-synthesis based on Noblit and Hare’s seven-step meta-ethnography.
Data sources Six electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, EMBASE, PubMed, SCI-Expanded—SSCI and Scopus (final search June 2022) were used to identify qualitative literature containing individual or focus group interviews. The transparency of reporting for each study was assessed using the Consolidated criteria for Reporting Qualitative research checklist.
Results The search identified 5002 articles, 107 of which were selected for full-text review. Seventeen articles from five countries with patients undergoing chemotherapy during exercise interventions were included. Eleven articles were included in the meta-synthesis, which comprised 193 patients with various cancer diagnoses, disease stages, sexes and ages. Four main themes were identified: chemotherapy overpowers the body; exercise in battle with side effects; a break from gloomy thoughts; and a question of survivorship.
Conclusions and implications The meta-synthesis emphasised that patients with cancer undergoing chemotherapy and simultaneously participating in exercise interventions may experience momentary relief from overwhelming side effects, even though full bodily recovery may be perceived as a distant prospect. The synthesis offers a sparse empirical basis for gaining insight into what patients experience existentially following exercise interventions. It is up to patients to independently apply the transfer value of exercise to their own existential circumstances.
- CHEMOTHERAPY
- ONCOLOGY
- HAEMATOLOGY
- REHABILITATION MEDICINE
- QUALITATIVE RESEARCH
Data availability statement
Data are available upon reasonable request. Additional data on the quality assessment of the included papers are available from christina.ingeborg.andersen@regionh.dk.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The validity of the qualitative studies was assessed using the Consolidated criteria for Reporting Qualitative research and found to be justifiable for inclusion.
The meta-ethnography approach provided an understanding of individual struggles of patients with cancer undergoing chemotherapy while participating in exercise interventions.
Omitting training studies based on predominantly digital health solutions may implicate that our results are not generalisable to this type of training situation.
The selection of informants in the synthesis may have resulted in a pre-positive bias toward exercise interventions.
Introduction
Worldwide, the rapid increase in ageing population implies an increased cancer risk, influencing the magnitude and societal impact of cancer, which varies across countries, diagnoses and sociodemographics.1 2 Extrinsic risk factors such as smoking, overweight, alcohol, infections and physical inactivity are shown to accumulate inversely with educational level and income.3–6
In recent decades cancer survival rates in economically developed countries have steadily improved,7–9 often resulting in years of complex treatment programmes, including surgery, radiation, immunotherapy and combined multi-drug chemotherapy with or without subsequent haematopoietic stem cell transplantation.10–12 Antineoplastic (chemotherapy) treatment continues to play a significant role, elevating the risk of symptoms and side effects such as fatigue, pain, physical deterioration, and functional and emotional decline.13–16 Concurrently, a significant interest has increasingly taken hold in the role of exercise and supportive care following a cancer diagnosis to reduce the disruption patients with cancer experience in their lives,17 18 especially in terms of supporting cancer survivorship through secondary and tertiary prevention since avoiding physical inactivity is highly prevalent among cancer survivors.19 20 However, immediate, and sustainable chemotherapy side effects are one of the most common obstacles to participating in exercise programmes.21 22
In accordance with recent guidelines,23 24 national Danish programmes like Body & Cancer25 26 and the Centre for Integrated Rehabilitation of Cancer Patients27–29 emphasise the importance of implementing exercise interventions early on to prevent and reduce physiological losses, also in at-risk populations specifically exposed to chemotherapy.30
Generic patient-reported outcomes are validated, for example, using the European Organisation for Research and Treatment of Cancer scale and the Functional Assessment of Cancer Therapy-Anemia subscale,31–33 and widely used to measure the significance of exercise for treatment side effects,34–39 and its impact on quality of life. These tools, which shed light on the functional and psychosocial aspects of the lives of patients with cancer, provide a number of symptom and side effect subscales. However, current patient-reported scales are not fully tailored to capture the details and scope of the profound experiences of patients regarding side effects while simultaneously participating in exercise-based interventions. To overcome this deficiency, qualitative evidence can help increase understanding of how patients perceive chemotherapy side effects beyond the clinic and interventional context, develop terminology, and transfer this sense of meaning into cancer survivorship.40 Existing guidelines, however, seldom reflect qualitative evidence.17 24 41 42 The failure to integrate qualitative evidence into guidelines is possibly due to the epistemological nature and methodology of qualitative research weighted against meta-analyses of powered randomised controlled trials widely accepted in the clinical research community.
To complement the methodology of meta-analyses, leading positioned qualitative researchers have reinforced the ideation of a similar synthesis of qualitative ethnographies.43 44 For example, in relation to cancer interventions, two qualitative meta-syntheses45 46 have explored the views of patients with cancer on participating in exercise or psychosocial interventions to support them in coping with their cancer diagnosis and treatment. Hoeck et al (n=33) provide valuable knowledge on the significance of psychosocial interventions,46 while Midtgaard et al (n=8) focus on participation in structured supervised training and obtaining primary data related to social interaction.45 Both studies, which identify unifying themes related to continuity in re-instituting a purposeful structure in everyday life along with cancer treatment, assert the value of psychosocial research.45 46 These meta-syntheses, however, do not focus on whether the exercise interventions compensate for the burden of symptoms and side effects from chemotherapy and the trajectory of a life-threatening disease.
Thus, inspired by meta-ethnography methodology, we aim to synthesise the perceptions of patients with cancer undergoing chemotherapy and the challenges they face while simultaneously participating in various exercise interventions, but also how the side effects and overall symptom burden impacted this. We seek to provide a deeper understanding to clarify the underlying rationale of exercise oncology and to supplement existing guidelines. Finally, based on our findings, we wish to emphasise areas of future research in cancer survivorship.
Methods
This qualitative meta-synthesis contained the following steps, which are based on Noblit and Hare’s seven-step meta-ethnography.47
Step 1
Involved the specific research question: how do patients with cancer undergoing chemotherapy perceive the interaction between chemotherapy exposure and a simultaneous exercise intervention?
Step 2
Comprised a systematic literature search strategy devised to retrieve references related to the study aim and that met the inclusion criteria.
Step 3
Consisted of three authors (CA, CSD, LA) separately reading and rereading the studies to identify and document first-order (participant experiences) and second-order interpretations independent of the main findings and one another. During this process, we aggregated findings from studies that shed light on patient experiences and impact of chemotherapy side effects.
Step 4
Involved two authors (CA, LA) determining how the studies were related. To compare the individual study findings, we drew diagrams containing meaning units to identify the categories that emerged. Four emergent themes were interpreted capturing the main findings of all included studies.
Step 5
Served to strengthen transparency and validity of the four main condensed themes. and involved two authors (CA, LA) examining the patient contributions (positive and negative), empirical based constructs and patient quotes in each study (online supplemental appendix 1). Similarities and differences in findings were noted, with a special focus on deviant cases (eg, improvement vs non-improvement in side effects: main theme 2).
Supplemental material
Step 6
Entailed three authors (CA, LA, TM) synthesising the four main themes to reach a higher level of abstraction and to develop a third-order interpretation using connectiveness and discussions on existing evidence in exercise oncology.
Step 7
Involved producing a structured report and discussion of the findings of the synthesis.
Inclusion and exclusion criteria
Inclusion criteria: (1) original qualitative peer-reviewed research articles, (2) interviews (individual or focus group interviews) with patients with cancer irrespective of sex, age, diagnosis and illness status (cancer stage and burden of disease) undergoing an exercise intervention with a client-professional interaction and performed during chemotherapy. All settings for physical exercise (home-based, hospital, community), and type of physical exercise (eg, strength training, endurance training, walking), supervised or unsupervised, group-based or individual. Studies using mixed methods were included if they presented qualitative findings separately.
Exclusion criteria: (1) reviews, meta-syntheses and papers not published in English, (2) studies based on interviews with healthcare professionals or cancer caregivers only and (3) patients with cancer not receiving chemotherapy.
Search strategy
A research librarian (AL) developed a comprehensive search strategy for six electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, EMBASE, PubMed, SCI-Expanded—SSCI and Scopus (final search June 2022). Online supplemental appendix 2 describes the entire search strategy.
Supplemental material
Sources and study selection
The final search strategy identified 8358 items, which were then imported into Covidence.org (https://app.covidence.org/reviews/active). Covidence identified 3356 duplicates, resulting in a remaining 5002 items. Three researchers (CA, LA, CSD) then screened the abstracts and excluded 4895 items, resulting in 107 eligible studies for full-text screening. Ninety studies were excluded based on: wrong patient population (n=31); wrong publication type (n=23); wrong setting (n=12); wrong study design (n=10); wrong type of intervention, for example, no exercise intervention during chemotherapy or the exercise programmes stated no time limit or digital health solutions without repeated professional-client face-to-face or video-telephone interaction (n=10); and other (n=4) (online supplemental appendix 3).
Supplemental material
The researchers discussed any disagreements before drawing up a final list of 17 articles for quality assessment, 11 studies of which were selected for the qualitative meta-synthesis.
The Consolidated criteria for Reporting Qualitative research (COREQ) checklist48 was used to assess each study’s transparency of reporting, and the research group added two supplementary criteria concerning ethical considerations. CA, TM, CSD and LA assessed all 17 studies, while MJ, KP, HBL, MM, CA, CSD and LA independently assessed three studies each. After comparing the COREQ assessments, CA and LA discussed any differences to reach agreement. Based on the COREQ assessment, no studies were excluded from this synthesis.
Figure 1 contains a flow diagram of the search and inclusion process.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.
Patient and public involvement
None.
Results
Study characteristics
Seventeen studies from five countries with 418 patients (18–80 years of age) were included. Table 1 presents the characteristics of the included studies (online supplemental appendix 4 contains the extended version). The studies included patients participating in exercise interventions during adjuvant chemotherapy or chemotherapy for advanced disease. The majority included patients with a mixed cancer diagnosis (n=249)49–54 or patients with breast cancer (n=99).55–60 The remainder of the studies included children, young people and adults with haematological disease,61 62 advanced lung cancer or colon cancer.63 64
Supplemental material
Characteristics of included studies (n=17)
The interventions lasted 6–24 weeks and the settings varied between hospital-based (n=9),49 50 52–56 61 65 home-based (n=4),57 58 60 62 a combination of settings (n=4)51 59 63 64 and group-based/supervised (9 out of 17).
The exercise interventions were cardiovascular and resistance training (n=11), walking programmes (n=2), a mixture (n=3) or tai chi (n=1). Most of the studies do not report the adherence rate in the interventions,49 53 56–62 64 65 but the rate was relatively high (74%–86.9%) for six studies.50–52 54 55 63 The studies used individual interviews (n=12),49–52 54 55 58 59 61 62 64 65 focus group interviews (n=3)53 57 60 or a combination of both (n=2).51 56 One study58 used telephone interviews only, while the other studies used face-to-face interviews.
COREQ assessment
The completeness of reporting varied across studies, with an average score of 19 (range 13–27) out of 32 items on the checklist clearly documented (online supplemental appendix 5 contains complete COREQ assessment for each study). Low rates of reporting were observed in describing the researcher/interviewer, with sex (item 4), experience and training (item 5) and characteristics (item 8) often not reported. All studies stated their methodological orientation (item 9), adequately described the sample (items 12 and 16), presented consistency between data and the findings (item 30) and clarified major themes (item 31). All studies considered ethical issues, with the exception of two.58 59 The validity of the qualitative studies was found to be justifiable for inclusion in the meta-synthesis.
Supplemental material
Meta-synthesis
Six studies were not included in the synthesis52–54 59 60 62 due to the following differences in scope: focused on max test52; quantitative mixed data weighted heavily53; focused on dose–response effect from prophylactic epoetin alfa54 62; parallel publication on an identical sample60; and compared feasibility between intervention and control in a pilot study.59
The meta-synthesis included 11 qualitative studies (n=193 patients).49–51 55–58 61 63–65 In studies that included adults, the average age was 50.4818–78 years, and there were 47 men and 133 women. Most studies (n=7)49–51 55–58 included patients with breast cancer (n=106), few studies included patients with haematological diseases (n=21)49 50 61 or patients with colorectal cancer (n=30),49–51 64 and one included patients with advanced lung cancer (n=15).63 One study65 included children aged 8–16 years (n=7 males, n=6 females), most of whom (n=10) had haematological diseases such as acute lymphoblastic leukaemia, acute myeloid leukaemia and lymphoma.
In accordance with Noblit and Hare’s seven-step meta-ethnography47 implying a comprehensive process of qualitative condensation, four main themes were identified: chemotherapy overpowers the body; exercise in battle with side effects; a break from gloomy thoughts; and a question of survivorship, each theme providing a line of argument in the perceptions of patients with cancer of participation in exercise while undergoing chemotherapy. A number of subthemes emerged within each of the four main themes (table 2).
Themes, subthemes and studies (online supplemental appendix 1 contains additional citations)
Main theme 1: chemotherapy overpowers the body
Patients agree to receive chemotherapy in the hope of improving their own chance of survival. For some, the diagnosis and treatment trigger shock and anxiety, disrupting their daily life49 51 63: ‘It was a total shock to receive that diagnosis and of course it affects you negatively …’ (p808).63
Chemotherapy causes negative physical effects, impacting daily life49–51 55 57 58 61 63–65: ‘Before the illness I was super strong—on the top … Now I have hit rock bottom …’ (p366).49 Some patients feel that their body had broken down.49 51 55 57 58 The patients also describe the deterioration of their physical capacity49 50 55 57 58 61 63–65: ‘When I started chemotherapy, I couldn’t do more than lie on the sofa and vomit for four days. I was tired … and my body just refused …’ (p60).50
Children with leukaemia describe a significant change in their physical abilities: ‘I was the strongest in class before chemotherapy, and now I’m suddenly the weakest’ (p6).51
There is also a change from engaging in a high to a low level of physical activity, accompanied by body denial when diagnosed: ‘I thought I had the perfect body until I got cancer’ (p58).50
Most patients report that they experience cancer and chemotherapy as invading their bodies, making them feel weak, just as they have difficulty recognising themselves as a powerless victim of cancer.
Main theme 2: exercise in battle with side effects
There is a strong feeling of powerlessness among patients related to the noticeably negative physical changes that cancer and chemotherapy impose on their fitness level and appearance.49–51 55–58 61 63–65 Patients with various cancer diagnoses and chemotherapy regimens describe that their fatigue often worsens as the treatment programme progresses, despite participating in the exercise interventions49 50 57 58 63 64: ‘I have extreme fatigue all the time; I’m more and more tired as chemotherapy goes on’ (p240).58
In one study49 patients emphasise that chemotherapy-induced fatigue can be ameliorated through supervised, high-intensity training and turns into exercise-induced fatigue, which is characterised by temporary physical well-being and relaxation: ‘… I’m tired, but after physical training I’m tired in a nice way’ (p366).49
Patients with breast cancer express that pain was a key factor following chemotherapy.51 55–58 One patient says: ‘I was burning up inside …’ (p6),51 another stating: ‘It was horrific with all that pain … I felt like an invalid … I couldn’t do anything … No, on those days there was no way that I could exercise’ (p660).55
On a general level, patients tend to feel that they positively benefit from participating in exercise49 51 55–58 61 64 65 despite chemotherapy side effects. Some patients highlight their improved physical capacity as the most striking outcome of exercising49 56 61 65: ‘I can see that I have more muscles and that my body has become tighter. I’ve gained some weight since I’ve been here …’ (p367).49
Patients with inoperable lung cancer63 only feel a limited benefit from engaging in physical exercise: ‘In my case the effects did not last long. I have a blood percent that continuously lowers and then I can’t breathe … so the effect of exercising does not last long’ (p810).63
Despite the challenges that arose due to side effects some patients nonetheless participated, even on days when the chemotherapy was doing its best to thwart their bodies’ agenda.
Main theme 3: a break from gloomy thoughts
Patient quotes show that they believe that physical activity can provide a temporary reprieve from the emotional strain resulting from receiving a cancer diagnosis and treatment.49–51 55–58 61 63–65 Participation in exercise programmes can be perceived as a helping hand to manage anxiety: ‘Physical activity helps with anxiety’ (p416).61 Some patients49–51 56–58 61 64 point out that exercise can lessen feelings of despondency and depression: ‘Physical activity has been really important … when feeling down and depressed. Go outside and go for walks …. doing something!’ (pE15).57
Children with cancer explain that their lives are characterised by hours of intensive treatment and periods of isolation: ‘You don’t like having long boring days and feeling bad’ (p6).65 They point out that exercising together with classmates briefly boosts them physically and distracts them from gloomy thoughts: ‘Just the fact that you’re doing something instead of just lying here … and you feel a little happier afterwards … [after physical activity]’ (p7).65
Advice and supervision from healthcare professionals (nurses and physiotherapists) in the hospital-based interventions49 51 55 61 63–65 help to provide reassurance and create a feeling of security that benefits the patients emotionally: ‘I think it’s important there are professionals … you feel confident about what they teach you …, but I feel that they help me put in more effort than I would on my own’ (p2304).64 Likewise, social relationships and support from the patients’ network of family and friends51 57 58 also have a positive influence on their emotional state: ‘To all my friends I used to do sports with, it became natural to walk with me. If I had a bad day, I could send a text message and they would come and pick me up at home. It’s been really nice’ (pE16).57
Main theme 4: a question of survivorship
Once exercise programmes begin to draw to a close, patients reflect on their own future: ‘It was important to me to stop talking about the cancer and start talking about exercise … to change the subject’ (pE16).57
Half of the studies51 56–58 64 include descriptions of the patients’ dreams and plans after their chemotherapy and once the exercise programmes end. Unsurprisingly, life-threatening illness and tough treatment regimens leave their mark physically and mentally: ‘… cancer was the most crucial factor in reconsidering my way of life’ (p5).51
When the patients conclude their training programmes their outlooks change51 56–58: ‘After doing the programme, my body is much stronger. I’m doing well mentally [and] I have clear objectives for the future’ (p6).51 The patients express optimism about being able to use their body’s new resources as a tool to provide respite from their cancer diagnosis: ‘To me, it felt like running away from the illness. I realised that I could do something and even more than before I got sick’ (pE18).57 A positive interpretation of the importance of exercise for the patients’ survival is a recurring feature of the studies that include patients with cancer who receive adjuvant therapy.51 56–58 64
Patients with inoperable lung cancer63 do not see engaging in physical exercise as being life-prolonging but they do point out that getting together in a group gives them: ‘… a much clearer sense of their cancer diagnosis and a bleak prospect in terms of dying’ (p812).63 Group exercise alleviates the sense of loneliness and isolation in the patients with lung cancer.63 Another study50 involving young patients with cancer who had been top athletes prior to their illness but now had advanced-stage cancer likewise does not indicate that they have any explicit expectations regarding their own survival but rather indicate a shift in identity: ‘… from experiencing one’s identity as an athlete to one, powerless cancer victim’ (p60).50 This underlines the uncertainty patients feel concerning their interpretation of their own chance for survival.
Discussion
The present meta-synthesis includes data from eleven qualitative studies with 193 patients with cancer participating in an exercise intervention while undergoing chemotherapy. The patients offered detailed descriptions on how chemotherapy influenced their perception of their symptoms, side effects, activity level and appearance. Patients who were highly physically active prior to their illness describe the negative effects of chemotherapy.49 50 Patients with advanced-stage cancer49 50 61 63 65 and patients receiving adjuvant chemotherapy after surgery51 55–58 64 describe the side effects as being overwhelming and negatively affecting their sense of self, functioning, mood and behaviour.
Accordingly, the findings confirm that chemotherapy exposes patients to side effects and physical deterioration over an extended period. Various studies have shown that this effect may last for several months after termination of treatment.67 68 For children65 and patients with haematological disease,61 treatment involving stem cell transplantation can be more intensive and last for several years.69–73
In contrast to a recent meta-analysis among patients with breast cancer participating in exercise during adjuvant chemotherapy74 findings from our meta-synthesis reveal that fatigue persisted or increased over time and, to some extent, varied depending on the chemotherapy cycle.49 50 57 58 63 64 Few studies in this synthesis suggest that patients shift their focus, in that their side effect agenda is only momentarily displaced by an exercise agenda,49 with negative bodily decisions briefly taking a backseat. This displacement indicates that exercise does not permanently solve fatigue but can only temporarily displace negative bodily feelings.
In the populations in our meta-synthesis, the patients’ bodily experiences were dominated by confronting side effects, indicating that patients highly exposed to side effects continued to exercise to handle physical strain63 or to cope with pain.55 57
The third-order interpretation in the present meta-synthesis suggests that exercise interventions may provide a contextual break from the impact of medical cancer treatment, even though full bodily recovery may be perceived as a distant prospect or even as lost forever.75 However, some patients find that exercising in groups or individually constitutes a distraction that pushes aside intrusive experiences and gloomy thoughts related to cancer. Solid evidence shows an increased prevalence of depression and mood disorders in cancer populations76 77 and that causal mechanisms may be multi-factorial.78 Engaging in exercise may offer a means for fighting against side effects and provide benefits by promoting physiological and psychosocial steps that encourage more hopeful thoughts.51 The various experiences do not occur evenly among individuals, groups of cancer diagnoses or prognoses, for example, in terms of breaking with isolation,63 65 mirroring oneself among others,50 55 solidarity and new friendships,57 79 bodily awakening49 58 and thoughts of re-orientation.51 When the concrete research agenda aims at physical decline, these experiences surface, though unevenly among participants.56 61 The emotional benefits of pooled, randomised exercise trials in patients with breast cancer have a minor effect size, though numerous effects from exercise interventions on quality of life have been observed in cancer survivors.80
The present meta-synthesis suggests that getting a break from illness and side effects is beneficial since systematically scheduled breaks designed to strengthen the body may trigger a flow of thoughts on recovery and life prospects. However, the sustainability and importance of these breaks remain unclear and cannot be determined based on our meta-synthesis.
The knowledge gathered in this meta-synthesis is generally concerned with the individual struggles that patients undergoing chemotherapy tries to overcome through exercise participation. Nonetheless, these experiences are partly time limited within the context of the interventions, providing only a sparse empirical basis for gaining insight into the patients’ existential outlook during and after treatment. Irrespective of cancer diagnosis and prognosis, the patients seldom refer explicitly to their existential situation. It is nonetheless problematic and inadequate that the researchers in the included studies did not discuss and reflect more deeply on this aspect.
It is unclear to what extent the actual exercise intervention context helps the individuals to blot out their existential situation or to switch off gloomy and worrying thoughts. In line with findings in the meta-synthesis by Midtgaard et al,45 there seems to be a mutual agreement between the participants and the exercise team to facilitate a community. The overall aim of this community is to focus on the physical benefits in parallel with their underlying situation. However, the present and the meta-synthesis by Midtgaard et al45 point to different but complementary insights that illuminate the individual struggles with on-the-one-hand the invasive impact of chemotherapy exposure and on the other hand, the potential health promoting gains related group-based exercise interventions. Far less is unfolded in these two meta-syntheses, it leaves participants to independently determine how to take advantage of the transfer value of exercise and apply it to their existential situation.
Methodological considerations
In the present meta-synthesis, the research scope was the patients’ perceptions of side effects and the body’s possible physical and emotional deterioration due to treatment while simultaneously participating in exercise. This approach to data collection (n=11 studies) excluded qualitative studies on exercise performed during chemotherapy that did not meet the overall scoping criteria: emotional habitus,53 VO2max test52 and EPO drug evaluation.54 62 Likewise, studies were excluded from the meta-synthesis due to, for example, wrong population, wrong intervention or wrong study design (online supplemental appendix 3).
One limitation is the omission of exercise studies based on predominantly digital health solutions (distance delivery, mHealth, eHealth), even though our search strategy captured qualitative research on digital health solutions81 (online supplemental appendix 3). This choice was made mainly because this emerging field is less integrated in the existing meta-analysis of exercise interventions that the present meta-synthesis focuses on. We acknowledge the importance of digital health solutions and their potential benefits, for example, overcoming distance and transport challenges, the availability of wearable devices providing professional guidance, and their cost effectiveness. We recommend that more quantitative and qualitative research be done on the upcoming field of guided exercise and that meta-analysis and meta-synthesis subsequently be done on the outcomes.
We have not specifically made a distinction between findings from adults and children in the meta-synthesis since only one paper included children.65 This is a potential limitation and underscores the need of more qualitative research for children with cancer undergoing chemotherapy and participating in complementary exercise interventions.
Most of the included studies were qualitative and performed as part of hospital-based exercise trials,49 50 with two studies exclusively examining primary care settings.57 58 Participants were usually recruited from a selected background population that voluntarily signed up for exercise based on their own motivation, which implies a convenient sampling of informants across the studies. There were predominantly women with breast cancer receiving adjuvant chemotherapy,51 55–58 even though some studies strategically recruited participants from risk populations (advanced treatment, stages of disease, physically inactive lifestyle) using an outreach approach (doctor’s recommendation, nurse counselling) in hospital clinics.51 61 63 65 This unavoidable selection of informants may have resulted in a pre-positive bias to exercise interventions since the informants’ preferences already coloured their attitudes.
The meta-synthesis was based on every included studies irrespective of their COREQ assessment and thus considerations of internal validity did not influence the emergence of findings and interpretation. We found the studies justifiable for inclusion since they in general were lacking similar information on specific domains, for example, participants knowledge of the interviewer, interviewer characteristics, transcripts return and member checking (online supplemental appendix 5).
The analysis was guided by the empiricism, with no prior or post-theoretical anchor to determine what was selected. To support the external validation of findings, we discussed central aspects and other meta-levels found in the scientific literature. Based on the narrative heterogeneity of patient experiences,49–51 55–58 61 63–65 this meta-synthesis may help in understanding why meta-analyses generally only find an average, small effect size on health-related quality of life domains (eg, fatigue, physical function, quality of life),80 82–85 which may be due in part to the competing interaction, variation, and nuances resulting from chemotherapy and side effects but also the effort to rebuild the body during exercise. The patient-reported effect measures applied in the exercise interventions may not capture the most pivotal reasons for patient engagement in exercise, which are, as this synthesis indicates: the fight for survivorship and reconsidering one’s life.
Clinical implications
This synthesis highlights the fact that the majority of patients with cancer undergoing chemotherapy experience severe symptoms and side effects irrespective of whether they receive supportive medical treatment or take part in various exercise activities. As new complex cancer treatment regimens are being developed it is becoming a significant challenge for clinical cancer specialists to intervene with regard to side effects. This is why alternatives such as physical activity programmes are increasingly being developed and tested with a view to strengthening the body and potentially reducing side effects, physical deterioration, and emotional distress. Findings from related qualitative studies were aggregated to generate an evidence basis for use by healthcare professionals in oncological and haematological practice. A stronger emphasis on the patient’s existential situation and their fight for survivorship could be incorporated in medical clinics as well as in exercise rehabilitation programmes, which may form the core agenda for cancer survivors.
Conclusion
This meta-synthesis included qualitative studies (n=11) based on patients with various cancer diagnoses, different disease stages, sexes, and ages participating in group or individual exercise interventions while receiving chemotherapy. It identified four major themes: chemotherapy overpowers the body, exercise in battle with side effects, a break from gloomy thoughts, and a question of survivorship. To a large extent, we found that participants were left to independently determine how to take advantage of the transfer value of exercise and apply it to their existential situation. Our meta-synthesis showed that exercise interventions may provide momentary relief from overwhelming side effects, even when full bodily recovery is perceived as a distant prospect.
Data availability statement
Data are available upon reasonable request. Additional data on the quality assessment of the included papers are available from christina.ingeborg.andersen@regionh.dk.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors All authors (except AL) conceived and designed the study. AL developed the search strategy and imported the studies to Covidence.org. HBL, KP, MM, MJ and TM performed the quality assessment (COREQ) of three studies each, while CA, CSD and LA performed the quality assessment (COREQ) of all studies. CA, CSD and LA selected and assembled the data. CA, CSD, TM and LA carried out the data extraction, analysis and interpretation. All authors contributed to the writing of the manuscript and approved the final manuscript. Author acting as guarantor: CA.
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.
Competing interests None declared.
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.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.