Shinshu Med J, 68⑶：149～157, 2020

Relationship between Physical Activity and Health-related Qualityof Life in Hospitalized and Terminally Ill Cancer Patients
Takayoshi Yamaga1）2）3）＊, Keiji Matsumori2）, Yusuke Otsu2）
Saki Nakasone4） and Tomonobu Koizumi1）
1） Department of Comprehensive Cancer Therapy, Shinshu University School of Medicine
2） Department of Rehabilitation Medicine, Shinshu University Hospital3） Department of Occupational Therapy, Health Science University4） The Melody Home Nursing Station

Background : The relationship of physical activity (PA) and health-related quality of life (HRQoL) in hospitalized
and terminally ill cancer patients has yet to be determined. The present study was performed to evaluate PA
status and the relationships between PA and HRQoL outcomes in advanced and hospitalized terminally illcancer patients.
Materials and Methods : Patients with advanced, and/or metastatic malignancies were eligible. PA had beenmeasured for 1 week using a uniaxial accelerometer and divided into “light” activity level on the best PA overthe past week (PA ＜150 minutes) or “high” activity on the best PA over the past week (PA ≥150 minutes).
HRQoL was measured by the European Organization for Research and Treatment of Cancer QLQ-C30 (EORTCQLQ-C30). In addition, cancer-related symptoms and the ability to perform basic movements and activities ofdaily living (ADL) were also measured. We examined differences in PA level by binomial logistic and multiple
linear regression analyses.
Results : Ninety-seven subjects were enrolled in the study. The high PA group (PA ≥150) had significantly
higher HRQoL and increased ability to perform basic movements and ADL. The most important factor associat­
ed with engagement in PA was the ability to perform basic movements.
Conclusion : This study showed that hospitalized and terminally ill cancer patients with PA ≥150 minutes per
week had higher HRQoL. Advanced patients in hospitalization presenting with PA ≥150 have the potential for
improved HRQoL by palliative rehabilitation. Shinshu Med J 68 : 149―157, 2020
(Received for publication December 20, 2019 ; accepted in revised form February 6, 2020)
Key words : physical activity, palliative care, rehabilitation, QoL, medical service
Abbreviations : PA, Physical Activity ; HRQoL, Health-Related Quality of Life ; EORTC QLQ-C30, European
Organization for Research and Treatment of Cancer QLQ-C30 ; PPS, Palliative Performance Status Scale ; BMI,
Body Mass Index ; ESAS, Edmonton Symptom Assessment System-Revised ; ABMS II, Revised Version of the
Ability for Basic Movement Scale
However, maintenance of quality of life (QoL) andＩ Backgroundphysical performance are important issues even in

Survival in patients with advanced cancer can bepatients with advanced cancer, especially in cases

1）with incurable disease and late in the clinical course

prolonged with improvement of cancer treatment .

and/or receiving end of life care. Health-related＊

Corresponding author : Takayoshi Yamaga
Department of Occupational Therapy, Health Science
University, 7187, Kodachi, Fujikawaguchiko-machi,
Minamitsuru-gun, Yamanashi 401-0380, Japan
E-mail : t.yamaga@kenkoudai.ac.jp

No. 3, 2020

quality of life (HRQoL) has been used to evaluate
physical and/or psychosocial adverse outcomes andsymptoms. Indeed, HRQoL assessment has become aparadigm for patient-centered outcome measures
149Yamaga・Matsumori・Otsu et al.

under clinical conditions. A diverse range of symp­

static malignancies. Other eligibility criteria included

toms are associated with declining HRQoL, including

the following : 1) age ＞20 and ＜75 years ; 2) estimat­

cancer-related fatigue, reduced appetite, nausea anded life expectancy ＞3 months ; 3) Eastern Coopera­

vomiting, dyspnea, depression, and physical impair­tive Oncology Group performance status 0-3 ; 4) ablements2）3）. Factors that reduce HRQoL can potentiallyto wear the activity meter ; and 5) able to provide

be modified, and intervention strategies to improveinformed consent and comply with study require­or prevent HRQoL are a major concern in patientsments. Patients were excluded from the trial for any

with advanced cancer.

of the following reasons : 1) active infection ; 2) clini­On the other hand, physical activity (PA) definedcally significant cardiovascular and/or respiratory

as any bodily movement produced by skeletal mus­disease, including ischemic heart disease and pre­4）cles that results in energy expenditure can improvesenting respiratory failure ; 3) pleural or pericardial

HRQoL in patients with cancer or in cancer survi­

effusion requiring drainage ; 4) active brain metasta­

5）

vors . Several clinical trials have revealed that reha­

sis ; 5) uncontrollable diabetes mellitus or hyperten­

bilitation treatment may be useful in cancer pa­

sion (blood pressure ≥150/100 mmHg) ; 6) Palliative

5）

tients . However, the optimal model remains to be

Performance Status Scale (PPS) score ≤30 ％ , andelucidated for patients with incurable advanced can­severe medical comorbidities that grossly impaired

cer. Some previous studies were conducted in newly

mobility ; 7) hemoglobin ＜9 g/dL, platelet count ＜diagnosed patients with advanced incurable cancer

70000/μL ; 8) history of thrombotic or hemorrhagic

6）

and in outpatient settings . As disease progression isdisorders ; or 9) otherwise defined as ineligible by aassociated with deterioration of symptoms and de­physician. Concomitant active malignancy, dementia,

7）

cline of physical function , the PA status and HRQoL

and other conditions causing confusion were consid­

in advanced cancer patients, particularly terminallyered as contraindications for PA. Eligible partici­

ill cancer patients, are unknown. In Japan, patientspants were required to read about the right to with­

with deterioration of cancer-related symptoms anddraw, confidentiality, and the risks and benefits ofdeclining physical function are commonly treated inparticipation in the study, and each patient provided

hospital, and almost 80 ％ of cancer patients die in

written informed consent.

8）

hospital .

Ｂ

Study design

This study was performed to evaluate PA status

The primary objective of the study was to assess

and the relationship between PA and HRQoL out­

the association between PA and global health statuscomes in advanced and hospitalized cancer patients,

as measured by the European Organization for Re­

i.e., terminally ill cancer patients.

search and Treatment of Cancer QLQ-C30 (EORTCⅡ
ＡMaterials and Methods

Study population

QLQ-C30)9）. The EORTC QLQ-C30 incorporates ninemulti-item scales : five functional scales (physical,role, cognitive, emotional, and social), three symptom

This study was approved by the institutional re­scales (fatigue, pain, and nausea and vomiting), and aview board of Shinshu University School of Medicine

global health and QoL scale. Secondary objectives(document number : #2242) and was conducted inwere evaluation of factors that could affect PA in

accordance with the principles of the Declaration of

hospitalized patients with advanced malignancies.

Helsinki. Patients hospitalized at Shinshu University

This was a cross-sectional study. On the first day

Hospital were eligible for inclusion in the presentof the study, initial assessment, including demograph­study, and enrollment and registration were per­ic variables, such as age, sex, height, weight, andformed prospectively. Patients were eligible if they

medical variables, such as current medications, labo­

had histologically or cytologically proven unresect­

ratory data, PPS, symptoms, HRQoL and physicalable, locally advanced, and locally recurrent or meta­

performance, was performed. Body mass index (BMI)150

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Physical activity and QOL in cancer patientswas calculated from measured height and weight

MET), moderate (3.0-6.0 MET), and vigorous (＞6.0

2[weight (kg)/height (m )]. Physical performance

MET) intensity activity15）. The validity of the Life­

was assessed by rehabilitation staff observing thecoder GS used in the present study has been con­participant’s performance. It was assessed by thefirmed for measuring activities, including walking,

Revised Version of the Ability for Basic Movement

and providing an objective measure of PA15）. At the

Scale (ABMS II) which examines the limitation ofend of this week, the patients retrospectively docu­

10）

performing basic movement , and the Functional

mented their HRQoL during the monitoring period

Independence Measure score based on how muchusing EORTC QLQ-C30.

assistance was required for the individual to carryＣ

11）

Statistical analysis

out ADL . ABMS II consisted of six grades (6＝Participants were divided into two categories

complete independence, 3＝partially dependent, 1＝

based on “light or greater” activity level on their

total assistance) for evaluating the ability to perform

best PA over the past week (PA ＜150 minutes per

the five basic movements : “turn over from the su­

week vs. PA ≥150 minutes per week)16）17）. Data arepine position,” “sit up,” “remain sitting,” “stand up,”shown as the mean ± SD. The distribution of eachand “remain standing.” The Functional Independence

variable was checked for normality using the Kolm­

Measure consisted of seven grades (7＝complete in­ogorov-Smirnov test. Differences in medical and de­dependence, 3＝moderate assistance, 1＝total assis­

mographic variables between participants in the twotance) for evaluating the ability to perform activities

PA category groups were tested using Wilcoxon’sof daily living (ADL). In this study, the motor sub­rank sum test.

scale (m-FIM) was ; eating, grooming, bathing, dress­

We analyzed differences in PA levels by binomial

ing (upper and lower body), toileting, bladder andlogistic and multiple linear regression (direct meth­bowel management, transfers, walking/wheelchair,ods). The dependent variable was PA (0＝PA ＜150

stairs.

minutes, 1＝PA ≥150 minutes). Variance Inflation

The patient group also completed the Japanese

Factor was used to check for multicollinearity. Pre­version of the Edmonton Symptom Assessment Sys­

dictive and complexity characteristics of the model12）

tem-Revised (ESAS) , which covers nine items, in­were considered during modeling. Covariates includ­cluding physical, psychological, and wellbeing sub­ed demographic factors (age, sex, BMI) and medical

scales, and has also been widely tested and validated

factors (comorbidities, current treatment, cancer di­in palliative care populations. Self-efficacy was as­agnosis). Data were analyzed using SPSS version 25.0

13）
14）

software (IBM). In all analyses, p＜0.05 was taken tosessed by the General Self-Efficacy Scale (GSE).

The General Self-Efficacy Scale is a 10-item psycho­
metric scale that is designed to assess optimistic
self-beliefs to cope with a variety of difficult de­indicate statistical significance.
Ⅲ

Results

mands in life. Physical activity (PA) was measured

Recruitment into the present study was performed

using Lifecoder®GS (Suzuken Co. Ltd., Nagoya, Ja­

from September 2014 to May 2017. The CONSORTpan). Lifecoder®GS was placed on a line with thediagram in study participants is summarized in Fig.

anterior superior iliac spine of each participant, and

1. Although a total of 260 patients were recruitedparticipants were asked to wear the activity monitor

into the present study, 132 patients did not meet thefor a week from the time of the survey and to re­inclusion criteria, and three withdrew consent.

move the activity monitor when bathing or shower­

Therefore, 125 patients were eligible for inclusion ining and during radiotherapy treatment. This activity

the present study. The reasons for withdrawal in­monitor was based on a uniaxial accelerometry sen­cluded general fatigue (n＝1) and feeling too ill (n＝sor that computed step counts, total, and walking ac­2). Life recorder devices were provided to all partici­

tivity level every 4s and classified it as light (＜3.0pants, but 23 of 125 (18 ％) did not fully utilize theNo. 3, 2020151

Yamaga・Matsumori・Otsu et al.

260 Initiated contact about study
135 Excluded
132 Did not meet inclusion
criteria
3 Declined to participate

125 Patients consented to the Study
30 Missed PA data
23 Did not utilize the device
7 Lost accelerometer
95 Included in the analysis
Fig. 1

Flow of participants through the study

device. Seven of these 125 patients Fi
(6 ％)
ac­
1 lostFl theof pacelerometer. Therefore, full analyses were conducted

Binomial
and multiple linear regression
hrough th logistic
stud
analyses of predictive factors for PA were performedin 95 patients.

and the data are shown in Table 4. When adjusted

The median time spent on moderate or above PA

for several factors (age, sex, BMI, number of comor­load by all subjects in the present study was 5 [0.6-bidities), ABMS was the most predictive factor for17] minutes per week, and a maximum of 145 min­PA. Furthermore, patients with higher PA were sig­utes per week. The clinical characteristics of patientsnificantly related to ABMS (OR＝2.249, 95 ％ CI :in the present study and the comparison between

1.062-4.764), when adjusted for both demographic

the two PA levels are shown in Table 1. Patientsfactors and current medical treatments.

with PA ＜150 minutes had significantly lower albu­Ⅳ

min and PPS, and significantly higher PS compared

Discussion

to patients with PA ≥150 minutes. Other baseline

We found that subjects with PA ≥150 minutes pervalues were not significantly different between theweek had higher QLQ-C30, ABMS, FIM, and GES

two PA categories. Descriptive data for PA, EORTC

compared to subjects with PA ＜150 minutes. On the

QLQ-C30, ABMS, m-FIM, and ESAS are presented

other hand, ESAS results indicated no significant dif­in Table 2. There were no subjects with moderate

ferences. Based on these results, we concluded that

activity intensity that reached the recommended lev­PA ≥150 minutes per week is related to improved18）

els (moderate PA ≥150 minutes) . Patients with PA

HRQoL in hospitalized patients with advanced can­≥150 minutes had higher global health status, physi­

cer.

cal functioning, role functioning, emotional function­

The current guidelines for cancer survivors rec­ing, and social functioning. In addition, statisticallyommend 150 minutes or more of moderate or higher

significant differences were observed in scores of

PA per week17）. However, the PA level in patients

ABMS, m-FIM, and GES : patients with PA ≥150

enrolled in the present study was lower than that inminutes had a higher status. The same results were

the PA guidelines for cancer survivors17）, and none ofobtained in sub-analysis, even when only light PA

the participants achieved 150 minutes or more of

was classified at 150 minutes per week and analyzed

moderate or higher PA per week. Very few of our(Table 3).

participants could perform moderate or higher PA,

152

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Physical activity and QOL in cancer patients
Table 1

Characteristics of the participants

Characteristic

PA ≥150 minutes
n＝43

PA ＜150 minutes
n＝52

66.2±10.6
27 (63)70.6±9.0
31 (60)8 (19)
25 (58)10 (23)15 (29)30 (58)7 (14)

11 (26)6 (14)
13 (30)19 (37)7 (14)
9 (17)

3.4±0.7
11.4±1.7
2.7±3.5

3.1±0.6
11.5±1.8
3.4±4.5 a

18 (42)10 (23)5 (12)4 (9)
6 (14)

22 (42)11 (21)9 (17)2 (4)
8 (16)

Age, yr
Male sex, no. (％)
Body-mass index, no. (％)
Thin (＜18.5)
Healthy (18.5-25)
Obesity (＞25)
Comorbidities, no. (％)
Heart disease
Diabetes
Other
Laboratory data
Alb＊
Hb
CRP
Cancer diagnosis, no. (％)
Lung
Head and Neck
Gastrointestinal/Liver
Unknown
OthersPS Median [IQR]＊
PPS Median [IQR]＊
Current treatment, no. (％)
Chemotherapy
Radiation
Death (＜180 days), no. (％)
Discharge, no. (％)
Home
Other hospital
Death
In-hospital daysaData are means ± SD.
PA : physical activity.

＊

2 [1, 2]

3 [2, 3]70 [70, 90]

55 [40, 60]

12 (28)16 (37)7 (16)

10 (19)10 (19)16 (31)37 (86)3 (7)3 (7)30.0±21.3

36 (69)9 (17)
7 (14)
36.7±28.9

Data were available for 49 patientsp＜0.05considering the fatigue, cachexia, and weakness en­

ally to 150 minutes per week of PA21）. Our results

countered by advanced cancer patients. It is difficult

showed that even if most of the PA is of light inten­

for patients with advanced cancer to increase moder­sity, PA ＞150 minutes per week can have a positive

ate or higher PA. Therefore, based on our results,

impact on HRQoL in hospitalized and terminally ill

the recommendation was unsuitable for hospitalized

cancer patients. This finding may be significant forand terminally ill cancer patients in Japan. However,cancer patients who are unable to participate insystematic reviews have provided evidence thatmoderate systematic PA programs. Evidence fromhigher PA levels in patients with advanced cancer

observational studies suggests that light PA, inde­

are associated with greater HRQoL and improved

pendent of moderate PA, is associated with better

19）
20）

. For those engaging in physicalhealth benefits22）. Previous study suggested that in­inactivity, the recommendation is to incorporate acreasing light PA may be a viable approach to re­

few minutes of increased activity, to build up gradu­

ducing HRQoL decline in cancer survivors who were

physical status

No. 3, 2020

153

Yamaga・Matsumori・Otsu et al.
Table 2 Quality of life, symptoms, basic movement, self-efficacy, and ADL differences between
participants with PA ≥150 minutes and PA ＜150 minutes
Median [IQR]

EORTC QLQ-C30
Global health status
Physical functioning
Role functioning
Emotion functioning
Cognitive functioning
Social functioning
ESAS
ABMS
GES
m-FIM
PA, minutes/weekLight
Moderate
Vigorous
Steps

PA ≥150 minutes(n＝43)

PA ＜150 minutes(n＝52)

p-value

33.3 [16.7, 50.0]
66.7 [40.0, 80.0]
33.0 [16.7, 66.7]
75.0 [33.3, 91.7]
50.0 [0, 83.3]
50.0 [16.7, 83.3]
20.0 [15.0, 27.0]
30.0 [29.0, 30.0]
24.0 [21.0, 30.0]
86.0 [77.0, 91.0]

25.0 [8.3, 41.7]
20.0 [0, 46.7]
0 [0, 33.3]
41.7 [16.7, 72.9]
50.0 [16.7, 66.7]
8.35 [0, 50.0]
40.0 [23.5, 53.5]
28.0 [26.0, 29.0]
20.0 [11.0, 28.0]
62.5 [50.0, 76.8]

0.032
p＜0.01p＜0.010.030
0.611
p＜0.010.298
p＜0.01p＜0.01p＜0.01

213.7 [168.1, 285.6]
19.4 [7.6, 37.5]
0.7 [0, 0.7]
20811 [15138, 28078]

46.5 [19.7, 81.7]
0.9 [0.1, 4.4]
0 [0, 0.2]3957 [1740, 7105]

p＜0.01p＜0.010.026
p＜0.01

Table 3 Quality of life, symptoms, basic movement, self-efficacy, and ADL differences between participants
with light PA ≥150 minutes and light PA ＜150 minutes
Median [IQR]

EORTC QLQ-C30
Global health status
Physical functioning
Role functioning
Emotion functioning
Cognitive functioning
Social functioning
ESAS
ABMS
GES
m-FIM

light PA ≥150 minutes(n＝39)

light PA ＜150 minutes(n＝56)

p-value

41.7 [16.7, 50.0]
66.7 [46.7, 80.0]
33.3 [16.7, 66.7]
66.7 [33.3, 83.3]
66.7 [0, 83.3]
50.0 [16.7, 83.3]
32.0 [26.0, 44.0]
30.0 [29.0, 30.0]
24.0 [20.0, 30.0]
85.0 [77.0, 91.0]

29.2 [8.3, 41.7]
23.4 [1.7, 46.7]
0 [0, 33.3]
41.7 [16.7, 72.9]
50.0 [16.7, 66.7]
16.7 [0, 50.0]
40.0 [25.0, 51.8]
28.0 [26.0, 29.0]
20.0 [11.3, 28.0]
63.0 [50.5, 83.0]

0.048
p＜0.01p＜0.010.033
0.420
p＜0.010.346
p＜0.010.016
p＜0.01

Table 4

Predictors of PA

Multivariable Model 1 a
ABMS
m-FIM
ESAS
GES

154

OR (95 ％ CI)

Multivariable Model 2 b
OR (95 ％ CI)

2.326 (1.114-4.859)
1.055 (0.978-1.138)
1.037 (0.986-1.090)
1.069 (0.982-1.163)

2.249 (1.062-4.764)
1.067 (0.983-1.158)
1.028 (0.976-1.083)
1.063 (0.976-1.159)

a

Adjusted for age, sex, BMI, number of comorbidities.

b

Adjusted for model 1 plus chemotherapy, radiation.
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Physical activity and QOL in cancer patientsunable or reluctant to initiate or maintain moderate
23）

had several limitations. First, the study population

PA . We found that a certain amount of PA (PA ≥consisted of hospitalized cancer patients in a single

150 minutes per week) had a positive effect on im­

institute. The criteria for hospitalization varied

proving HRQoL even in terminally ill cancer pa­

among patients and the conditions of the disease. In

tients. The results of the present study suggest that

addition, there were many types of cancer and thePA ≥150 minutes per week, even if mostly of lightclinical backgrounds also varied among the enrolledintensity, such as walking, may be beneficial for ter­patients. Further studies are required to clarify what

minally ill cancer patients. To our knowledge, notypes of cancer patients could benefit from cancer

models of palliative rehabilitation for patients withrehabilitation. Second, our study did not measure sit­advanced cancer have yet been established. Our datating time, which is known to be a health risk factor

could provide new insight for clinicians to integrate

independent of PA24）25）. Studies in advanced cancer

palliative cancer care, especially in patients with in­patients revealed that sitting time affected psychoso­

curable disease and terminally ill cancer patients. A

cial functionality rather than time spent on PA26）.

randomized phase III study indicated that early palli­

Further evaluation of sitting time in addition to PA

ative care was associated with prolonged survival in

may be more informative for terminally ill cancer

patients with advanced and/or metastatic non-small

patients. Finally, health insurance for medical ser­22）

cell lung cancer . Interestingly, the survival benefit

vices, particularly during hospitalization, is quite dif­

was associated with improvements in HRQoL andferent among countries. Therefore, the results of thedepressed mood. Given the progressive nature of thepresent study may not be generalizable to cancer

illness, improving HRQoL and mood in terminally illpatients in other countries.

cancer patients is a major challenge. Our data sug­

In conclusion, we showed that PA ≥150 minutes

gested that palliative rehabilitation using a protocol

per week was associated with higher HRQoL evenwith PA ≥150 minutes per week could contribute toamong hospitalized and terminally ill cancer patients.

better HRQoL in terminally ill cancer patients.

Palliative rehabilitation using PA ≥150 minutes per

In the present study, we found no significant dif­ference in ESAS (cancer-related symptoms) between

week of physical activity may be useful to improve
QoL in terminally ill cancer patients.

the two PA categories. It is unlikely that the cancer-

Acknowledgments

related symptoms could affect the PA status. Thismay be because patients in both PA categories were

There was no funding associated with this study.

recruited after improvement of symptoms by medi­

We thank the patients and their families for theircal treatments, such as administration of opioids, etc.

support and participation in this study. We would

To our knowledge, this is the first study to clarify

like to acknowledge the medical staff, Department of

the relationship between light PA and HRQoL, andRehabilitation Medicine Shinshu University Hospital,

the capability to perform basic movement in termi­

for patient recruitment.

nally ill cancer patients. However, the present study
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