Introduction

Health promotion and health improvement are based on removing potential health risks and reducing morbidity and premature mortality. Analyses of global epidemiological studies show that effective prevention can reduce mortality from cardiovascular and oncological diseases by up to 50%. It is possible to change the behavior of individuals and groups toward a healthy lifestyle by effectively providing information about the influence and importance of individual factors for health, as well as by offering and making available conditions for positive habits (nutrition, environmental cleanliness, physical activity, relaxation, etc.) (NPPZ SR, 2021-2030).

The second most common cause of death in Slovakia is oncological diseases. In 2023, 13 432 people died from oncological diseases, accounting for 25% of total deaths in the Slovak Republic. This is 2% more than in 2011. In 2023, 103 162 hospitalizations with oncological disease were reported, which is 10.5% of all hospitalizations. In terms of individual patients, this represents 49 006 patients. The share of male patients was 44%. Among hospitalized men, the most common diagnoses were malignant tracheal and lung cancer—2 108 people, malignant bladder cancer—2 012 people, malignant colorectal cancer—1 643 people, malignant prostate cancer—1 640 people and malignant rectal cancer—1 245 people. Among hospitalized women, the most common were: malignant breast cancer—4 291 people, uterine leiomyoma—3 242 people, benign ovarian tumor—2 445, malignant colorectal cancer—1 328, malignant body of uterus—1 123 (National Oncology Register, 2024). The National Program for Health Support (NPPZ SR, 2021-2030) targets prevention of oncological diseases and is part of diverse approaches to protect and support population health. Education and motivation is a means focused on improving quality of life, removing or mitigating health-damaging influences by promoting a healthy lifestyle among the population with the goal of minimizing health risks in behavior. In Europe, in people who follow a healthy lifestyle in line with cancer prevention recommendations, expected cancer risk is 18% lower compared to people whose lifestyle and body weight do not align with these recommendations. This reduction was estimated in relation to a healthy lifestyle that includes maintaining normal body weight (BMI from 18.5 to 24.9 kg/m2, in those aged 65+ up to 26.9), avoiding foods that promote weight gain; performing moderate activity for at least 30 minutes per day; breastfeeding; consuming mainly plant-based foods; limiting red meat intake; avoiding processed meat products and limiting alcohol consumption. Regular physical activity is the basis of lifestyle change and supports other changes, especially nutritional ones, but also smoking cessation and stress management (NPPZ SR, 2021-2030).

Physical activity and exercise are a major component of primary prevention of oncological diseases, but also an important non-pharmacological treatment method for these diseases and a means of preventing complications of chemotherapy and radiotherapy (Líška, Stráska, Pupiš, 2020).

Aim and methodology

The aim of the paper is, using a narrative review method, to summarize and interpret the conclusions of studies dealing with the benefits of physical activity in the prevention of oncological diseases, as well as its benefits during treatment of oncological diseases. To effectively evaluate and provide a rich synthesis of evidence, it was necessary to review published studies, systematic reviews and meta-analyses of outcomes related to physical activity in oncological patients in domestic and international literature.

Physical activity in prevention of oncological diseases

Physical activity can be defined as any body movement that results from skeletal muscle activity (voluntary muscle contraction). Exercise represents a structured form of physical activity that typically occurs repeatedly over a period of time and leads to improved physical fitness, performance, and health (Ukropcová et al., 2015). Regular physical activity increases physical work capacity, or fitness, defined as the “ability to perform physical activity from moderate to high intensity without excessive fatigue and the ability to maintain this capacity throughout life” (Egnerová et al., 2001). Physical inactivity is a proven independent risk factor for chronic diseases (Ukropcová et al., 2015). It has been shown that participation in regular physical activity reduces the risk of ischemic heart disease and stroke, diabetes, hypertension, depression, colorectal cancer and breast cancer. In addition, physical activity is a key factor in energy expenditure and is therefore essential for energy balance and weight regulation (WHO, 2021). Physical activity improves psychological condition and reduces the risk of undesirable habits such as drug dependence, smoking and alcoholism. According to WHO recommendations (2021), the optimal dose of physical activity is 10,000 steps per day, 5 times per week 30 minutes, or 3 times per week for 1 hour of moderate-intensity physical activity, plus resistance training 2 times per week.

Despite these benefits, current studies indicate that about 70% or more of men and women in all age groups live below the level of physical activity that would substantially contribute to health (NCZI, 2022).

Current estimates of preventive fractions of oncological diseases suggest that roughly half of all cancer cases could be prevented through proper implementation of successful preventive measures, including adherence to the European code against cancer and cancer prevention. This code contains 12 core recommendations aimed at reducing cancer risk to the minimum, including maintaining healthy body weight, moving every day, and limiting time spent sitting (Schüz et al., 2019).

There are several biological mechanisms through which physical activity may protect against cancer. These include effects on blood sugar, insulin and related hormones, sex hormones and inflammation, as well as immune function, all of which influence cancer risk. Physical activity also helps prevent weight gain and helps maintain healthy body weight, which has an additional effect on lowering the risk of oncological diseases. The risk of developing various types of cancer is reduced by regular physical activity in a range from 0 to 30% in an individual. This mainly concerns the most common cancers in Europe—colorectal, breast, prostate and lung cancers, which also have the most extensively studied effects of physical activity. Based on data obtained so far, it is estimated that roughly 15% of all cancer occurrences in Europe could have been prevented by this type of prevention. The risk of these diseases is estimated to be about 4% lower in people who are moderately active for at least 30 minutes daily (or at least 150 minutes weekly) compared with people with lower physical activity levels (less than 15 minutes daily). Study results confirm that a healthy lifestyle combined with high fruit and vegetable intake, low body weight and physical activity increases the chance of survival (Cardoso et al., 2019).

According to Schüz et al. (2019), elimination of risk-related behavior could prevent at least 40% of oncological diseases.

Physical activity in treatment of oncological diseases

Including physical activity in treatment of oncological diseases, or in patients in remission, is highly important. The main mission of rehabilitation care for oncology patients is pain control, lymphedema care, maximum recovery and preservation of musculoskeletal function, education, psychological support, and ensuring optimal quality of life. For the optimal functioning of the rehabilitation process, active participation is needed from the patient, the whole care team, and not least the family and social environment. Their role is to provide the patient with substantial psychological support, and to propose approaches to improve function and mobility, independence and self-sufficiency.

The safety and benefits of physical activity in patients who have had oncological disease were confirmed by ACSM, the International Multidisciplinary Roundtable on Physical Activity and Cancer Prevention and Control (2018), which recommended that every such patient in remission should maintain at least the minimum recommended physical activity.

Different types of physical activity, individually tailored to each person, serve as a preventive or rehabilitation approach. Individually prescribed physical activity can bring improvement in:

  • stabilization or activation of the immune, hormonal and circulatory systems,
  • reduction of fatigue syndrome,
  • psychological well-being,
  • patient quality of life,
  • self-esteem and self-confidence (Campbell et al, 2019; Wiskemann, et al., 2015).

Campbell et al (2019) name several validated complementary methods that supplement standard antineoplastic treatment in order to support it and contribute to improved patient health status. Each method is defined by clinical efficacy studies—evidence based medicine (EBM). For all of them, therapeutic intensity, duration, and possible risks are established depending on cancer type and stage. Physical activity is included among such complementary methods.

ACSM, International Multidisciplinary Roundtable on Physical Activity and Cancer Prevention and Control (2018), in recognizing the safety and benefits of physical activity in oncology patients in treatment or remission, also pointed to several specific gains from integrating physical activity into these patients’ lives. These include, for example, reduction of depressive and anxiety symptoms, reduced chronic fatigue, and improved physical function, quality of life, and sleep quality. For patients with breast cancer and possible development of limb lymphedema, physical activity was also identified as safe, when performed through individually tailored exercises.

Wiskemann et al. (2015) recommend physical activity for patients with oncological diseases to increase survival rates. They clearly state, however, that each recommendation must be interpreted with caution for each patient and with consideration of the patient’s diagnosis.

The level of physical demand selected for ill patients needs to be assessed professionally through various diagnostic tests. One simple and fast test is the Borg scale, which has levels from 6 to 20 and allows patients to rate their perceived exertion during a given physical activity. The number 6 at the beginning of the scale means “no exertion,” and the number 20 at the end represents “maximal exertion.” A value of 9 indicates simple activity, exercise (slow, comfortable self-paced walking). A value of 13 represents activity perceived as more demanding but still possible to continue without major discomfort. A value of 17 means perceiving activity where the person can persist, but must push through because it is already perceived as difficult. Endurance training for a patient should be somewhere from around 11 to 13–14 points on the scale (Borg, 1998).

Fig. 1 Borg scale. Source: Borg,1998.

A patient undergoing oncological treatment may begin to suffer from declining physical fitness and have trouble with everyday activities such as walking up stairs, carrying heavier objects, or walking long distances. Therefore, it is very important to work on the patient's physical fitness and performance, endurance, and muscular strength through the integration of regular movement. Correct and precise assessment of the level of self-sufficiency is the starting point in planning interventions. It is necessary to classify the patient's functional level so that independence and ability to manage daily activities are promoted. In comprehensive assessment of oncological patient status, nurses can use standardized international validated measurement tools—various ADL and IADL indices that quantify and objectify functional capacity in different areas of daily life.

Blanař, Horáčková (2024) assessed self-sufficiency in a cohort of 50 patients with hemato-oncological disease. The cohort included 23 women and 27 men, with an average age of 70.93 years, minimum 36 and maximum 82 years. The survey found that patients’ self-sufficiency decreased after chemotherapy— as shown in Tables 1, 2, and 3.

Tab. 1 Descriptive statistics of Barthel test of basic daily activities

Tab. 2 Barthel test before chemotherapy

Tab. 3 Barthel test after chemotherapy

The patient's performance status is also important in decisions between treatment modalities (indication for palliative chemotherapy, pleurodesis, surgical treatment of malignant bowel obstruction, placement of nephrostomy, etc.). Mobility or at least self-sufficiency in basic self-care activities is significant even in patients with advanced-stage oncological disease; conversely, helplessness and dependence on others markedly worsen suffering and depression. Sometimes a lifestyle change is enough to maintain self-sufficiency.

Marques et al. (2018) found that physical exercise alongside standard care for a patient with an oncological disease can improve quality of life, especially physical functioning, depression and fatigue. Many patients devote more time to physical activity during illness than before it. They unconsciously realize that physical activity reduces pathological fatigue, brings them joy, and gives them a sense of control over their health. It helps them achieve better physical fitness, faster treatment, and reduced fatigue and depression, which often accompany treatment.

Persoon et al. (2013), based on eight randomized studies, confirmed in oncology patients a favorable effect of physical activity on the cardiorespiratory system, lower-limb strength development and reduction of fatigue. Similarly, Moore et al. (2016) reported benefits of physical activity not only for cardiorespiratory fitness but also for flexibility, strength, and autonomic balance in patients with oncological diseases. Active movement improves immunity in some oncology patients. In sports-active patients, a longer interval until disease recurrence was observed than the usual average.

Wiskemann et al. (2015) recommend physical activity for oncology patients to increase survival rates. They emphasize that every recommendation must be interpreted with caution for each patient and with respect to their diagnosis.

In a 2019 meta-analysis of observational studies, physically active women after breast cancer showed up to 40% lower risk of death from this disease than women who were least active. Physical activity performed before and after breast cancer diagnosis was also associated in some studies with reduced breast cancer progression, occurrence of new lesions, or recurrence of breast cancer (Spei, Samoli, Bravi, et al., 2019).

Exercise helped improve sleep disturbances, anxiety and psychological state. Research has shown that exercise programs in patients with lung cancer increased performance and reduced fatigue (Hoffman et al, 2014).

Campbell et al. (2019) point out that physical activity also helps reduce side effects of chemotherapy such as cardiotoxicity or neuropathy, and can improve cognitive functions, nausea, pain, and even tolerance of treatment itself.

ACSM, International Multidisciplinary Roundtable on Physical Activity and Cancer Prevention and Control (2018), in recognizing the safety and benefits of physical activity in oncology patients in treatment or remission, also pointed to several specific benefits of integrating physical activity into the lives of these patients. These include, for example:

  • improvement of physical and psychological condition to help cope with limitations caused by the cancer itself or its treatment.
  • restoration of good physical fitness to return to everyday life.
  • improvement in ability to cope with stress, sleep disorders and emotional imbalance.
  • rebuilding lost self-confidence.
  • restoration of autonomy and independence, for example from caregivers.
  • managing treatment side effects—chemotherapy, hormonal therapy, targeted therapy, immunotherapy and/or radiotherapy—by minimizing side effects in daily life.
  • adopting healthy eating habits and maintaining optimal weight.
  • coping with sexual life problems.
  • reducing the number of hospitalizations. Various rehabilitation programs, some suitable before returning to work and others after return to full participation in life.

Conclusion

Over the past twenty years, physical activity has proven to be an excellent means of faster patient recovery during rehabilitation, recovery and return to physical performance, and not least it helps improve the quality of life of the treated patient and reduce stress throughout the treatment process. Its major benefit is not only as a form of rehabilitation but also as a form of prevention against many diseases, including oncological diseases.

Authors: PhDr. Mária Novysedláková, PhD. Mgr. Vít Blanař, Ph.D. PhDr. Katarína Zrubáková, PhD.

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