Exercise interventions on health‐related quality of life for cancer survivors

In the management of head and neck cancer, outcome is more than just cure and survival. The cancer and its treatment affect fundamental functions including communication, eating and social integration. There is a steady increase in the number of cancer survivors and ensuring the quality of that survival has becomes a key priority. Quality of life (QoL) as a concept has therefore become increasingly important in relation to patient outcomes following treatment for head and neck cancer. The World Health Organisation defines QoL as ‘An individual’s perceptions of their position in life taken in context of the culture and value systems in which they live and in relation to their goals, standards and concerns’. The Calman ‘gap definition’ describes QoL as the measure between age expectations or present experience, and the perceived and actual goals. Ferrans provided a comprehensive review of definitions of health-related QoL (HRQoL) and concluded that, ‘the literature contains a bewildering array of characterizations’. Therefore, any studies will be fraught with potential idiosyncrasies. There is a broad consensus among experts regarding the major domains of HRQoL. These domains comprise subjective assessments of physical, psychological, economic, social and spiritual well-being. Physical function includes performance of self-care activities, mobility and physical activities. Psychological functions include emotional well-being, anxiety, body image and depression. Social and economic functions include work or household responsibilities and social interactions. Spiritual well-being includes perspectives on one’s life as a whole. Health-related QoL also encompasses the negative aspects of the disease or treatment, or both, such as sexual functioning, neuropathy or cognitive changes, and chronic fatigue. The benefits of exercise on health status, length of survival, promotion of HRQoL and mitigating premature death are gaining wide attention. Evidence indicates exercise increases physical functioning among cancer survivors and facilitates positive physiologic and psychological benefits in cancer survivors during and after treatment. In addition, evidence suggests exercise enhances HRQoL in head and neck cancer. This systematic review by Mishra et al. included 40 trials, 38 of which were Randomized Controlled Trials and two were Clinically Controlled Trials. These trials allocated 3694 participants to either the exercise or comparison groups. Participants enrolled in the trials had various cancer diagnoses including breast, colorectal, head and neck, and others. All trials included participants who had completed active cancer treatment; however, some trials also included participants who were currently undergoing treatment. Exercise interventions tested in the trials varied greatly and included strength training, resistance training, yoga, walking, cycling, Tai Chi and Qigong. Health-related QoL and HRQoL domains were assessed using a wide range of measures. The review finds that exercise interventions may have beneficial effects on overall HRQoL and HRQoL domains including cancer-specific concerns (e.g. breast cancer), body image/self-esteem, emotional well-being, sexuality, sleep disturbance, social functioning, anxiety, fatigue and pain at varying follow-up periods among cancer survivors who are beyond active treatment for their primary or recurrent cancer. No evidence of effect was found for HRQoL domains such as cognitive function, physical functioning, general health perspective, role function and spirituality. The lack of evidence may be due to few trials assessing these outcomes, small number of participants in trials measuring these outcomes, and substantial heterogeneity between trials measuring these outcomes on the exercise programs implemented and measures used to assess the outcomes. The authors concede that results of the review need to be interpreted with caution owing to the risk of bias. All the trials reviewedwere at high risk for performance bias because blinding of participants is not possible in exercise intervention unless more rigorously controlled comparative designs are utilised to test the effects of exercise interventions. Performance bias becomes accentuated in trials where participants are asked to provide subjective assessments of outcomes such as HRQoL and HRQoL domains. In addition, the majority of trials were at high risk for detection bias as the outcome assessors were not blinded, were at high risk for attrition bias owing to inadequate handling of incom-