Physical activity levels, willingness, and preferences in liver Cancer Patients: A Cross-Sectional Study

doi:10.21203/rs.3.rs-3244608/v1

Background: Despite the benefits and feasibility of physical activity for cancer survivors, a large number of liver cancer patients were insufficient active. Therefore, the current study to identify the physical activity level, willingness, and preferences of liver cancer patients and determine any associations with selected demographic and medical variables.

Methods: A cross-sectional study was performed on a sample of 204 liver cancer patients. These patients completed a questionnaire anonymously, which collected information about their general and medical characteristics, as well as their willingness and preference to participate in physical activity programs. The International Physical Activity Questionnaire-Short Form (IPAQ-S) was used to determine their current physical activity levels.

Results: Only 29 participants (14.2%) were active but 150(73.5%) declared an interest in physical activity programs. Multivariate logistic regression showed that willingness to exercise was associated with time since diagnostic (OR:1.905, 95% CI:1.017 to 3.567, beyond 12 months vs. up to 12 months), current physical activity (OR:3.961, 95% CI: 1.159 to 13.538 for active vs. insufficiently active according to the recommendations set by the American Cancer Society). Patients lived outside city were less inclined to exercise (OR: 0.45, 95% CI: 0.23–0.86) than those who lived within city. Patients with higher scores on the Tampa Scale of Kinesiophobia were less likely to engage in the exercise program (OR:0.889, 95% CI: 0.831 to 0.950). The participates expressed a preference for exercise programs instructed by an oncologist, but also indicated that they were willing to do unsupervised exercise at home.

Conclusions: Liver cancer patients have been found to have insufficient activity levels; however, they have expressed a willingness to participate in personalized physical activity programs. The results of this survey can assist in tailoring interventions to help these patients achieve the recommended levels of physical activity.

physical activity

liver cancer

preferences

kinesiophobia

According to the World Health Organization’s 2020 cancer survey data[1] , liver cancer is the sixth most common cancer in the world and the third leading cause of cancer death. China accounted for 45.3% of the world’s total hepatocellular carcinoma (HCC) cases[2] . In addition, the country’s population-level economic burden of liver cancer is currently substantial and will continue to increase in the future[3]. Improvements in medical treatments significantly improving the survival rate of these patients[4]. However, only 46% of patients are diagnosed in the early stage, and most patients in the middle and late stages cannot be cured. Even after curative therapy, the 5-year recurrence rate remains as high as 70%[5] . Therefore, most liver cancer survivors live with the disease for the rest of their lives.

Cancer and anticancer treatment can lead to serious physiological and psychological problems, severely affecting the patient’s quality of life (QoL). The beneficial effects of physical activity (PA) on health are well-recognized. Despite the benefits related to PA, a large percentage of cancer patients are insufficiently active, and the PA level has been seen to decrease after cancer diagnosis [6-10]. PA intervention can improve muscle mass and function, prevent further skeletal muscle breakdown, improve cardiovascular fitness, and help patients maintain their autonomy in activities of daily life. In addition, exercise is associated with better clinical outcomes[11-13]. Compared to those with other chronic diseases or cancers, patients with liver cancer tend to have an overall lower physical activity level. Its causes are multifactorial and complex. It particularly affects patients in the decompensated stage: energy and protein malnutrition with associated sarcopenia (low muscle mass, strength, and function); physical limitations from ascites and lower limb edema. Eventually, this leads to frailty, a state of a decreased physiological reserve associated with a low QoL, poor clinical outcome, mortality.[14]

It is imperative to consider liver cancer patients' obstacles and preferences, enabling them to choose those PA program they consider both enjoyable and advantageous. [15, 16] . Global studies have explored the PA preferences of cancer survivors. [6, 7, 17], but data on the liver cancer are lacking. There were few differences in program or counseling preferences based on the type of cancer. Liver cancer often arises from cirrhosis and is commonly associated with liver dysfunction, an increased risk of variceal bleeding and hepatic encephalopathy, all of which impose specific limitations on physical activity. To bridge this knowledge gap, the survey was constructed with the following aims: (i)To determine the magnitude of the issue, that is, to estimate the prevalence of inadequate physical exercise among liver cancer patients; (ii) to analyze the patients’ characteristics associated with their willingness to participate in a future intervention program on PA; (iii) to describe patients’ preferences about PA. The rationale of the study is that understanding patients’ preferences and barriers to PA will make it easier for them to participate successfully in a future intervention study to improve their physical fitness.

Study Design and Participants

This study is a cross-sectional survey. Anonymous data from patients admitted to the affiliated hospital of Jiangnan University between December 2022 and June 2023 were collected and recorded. To be eligible, patients needed to be ≥18 years old, have a liver cancer diagnosis[18], and possess the capacity to complete the survey questionnaire (QEX) independently. Invited participants included liver cancer survivors at all stages, including those newly diagnosed, actively receiving treatment, or having completed standard treatment. Convenient sampling method was utilized to enroll patients from the medical records of Jiangnan University Affiliated Hospital. Selected patients were followed up and interviewed, and were asked to complete the survey questionnaire in the hospital's oncology ward during the visit. Researchers approached patients face to face, explained the purpose of the study, and requested their anonymous completion of the questionnaire to investigate exercise characteristics and preferences. Invited participants were systematically asked by the staff if they had already completed the survey at any other time/date prior to this QEX administration. A duplicate check was conducted using date of birth, sex, residence, and education level to identify any potential duplicates. Patients who expressed interest in participating were asked to sign an informed consent form and were given a leaflet describing the purpose of the study. The project has been approved by the Ethics Committee of Jiangnan University with reference number JNU20221201IRB14. All study procedures were performed in accordance with the latest revision of the Helsinki Declaration, and the study protocol was designed with adherence to Good Clinical Practice principles.

The Survey Questionnaire (QEX)

The QEX is a survey designed for liver cancer patients to self-report their PA level, willingness, preferences, and kinesiophobia. This questionnaire was developed through a co-design process involving patients (via patient associations) and experts from various fields, such as oncologists, kinesiologists, epidemiologists, and nurses. The pilot version of the QEX was based on a literature review[7, 8, 10] and was reviewed by the experts and patients to develop the current version. The survey is anonymous, and while it is self-reported, staff support was available to address any questions during the survey. The QEX consists of 52 items divided into four sections: General characteristics (Q1–Q10), Clinical features (Q11–Q16), PA level (Q17–Q23), and PA willingness and preferences (Q24–Q35), as well as the status of Kinesiophobia (Q36–Q52).

Questions 1–10: General Characteristics

QEX collects demographic, anthropometric, and socio-economic characteristics of patients, including age (categorized as <65 or ≥65 years), sex, place of residence (inside or outside of Wuxi City), education level, marital status, occupational status, perceived economic adequacy, body weight (kg), and height (cm) (both continuous). Body mass index (BMI) was calculated using weight (in kilograms) divided by the square of height (in meters) and categorized as underweight (BMI <18.5 kg/m2), normal weight (BMI 18.5–24.9 kg/m2), overweight (BMI 25–29.9 kg/m2), and obese (>29.9 kg/m2). [19].

Questions 11-16: Clinical features

The medical variables were completed by hospital staff based on electronic medical records and include disease status (in remission-cured/early/advanced), date of diagnosis (month/year), type of treatment (surgery/transcatheter arterial chemoembolization (TACE)/systemic therapy/radiotherapy/other), current treatment status (about to start/ongoing/completed), and Complications (hypertension, diabetes, coronary heart disease, stroke, arthritis, viral hepatitis, fatty liver disease, and others).The Child-Pugh score[20] was also included. The time since diagnosis was calculated by subtracting the date of diagnosis from the date of QEX compilation and categorized based on the median (≤12 months; >12 months).

Questions 17-23: Physical Exercise Level

The QEX inquiry about current PA level was based on questions from the International physical activity questionnaire (IPAQ)[21] ，The IPAQ is a reliable and valid instrument used to assess an individual's levels of physical activity, sedentary behavior, and exercise patterns. It has been widely utilized in epidemiological research, health surveys, and behavioral intervention programs across various countries and populations [22-24]. A detailed description of the computation of IPAQ is found elsewhere[25]. In brief: (i) The IPAQ enquires about the previous weeks’ time frequency (times/week) of vigorous, moderate and walking exercise; (ii) Each exercise intensity is associated with the metabolic equivalent of the task (MET): MET = 8 for vigorous, MET = 4 for moderate, MET = 3.3 for mild intensity walking; (iii) The IPAQ working group recommends the calculation of the weekly physical activity level (MET min/w) of the individual: the MET assigned to the physical activity × weekly frequency (d/w) × daily time (min/d). The sum of the three intensity physical activity levels is the total physical activity level. Physical activity level categorization: The IPAQ working group recommends classifying individual's physical activity level into three groups – low level, moderate level, and high level, based on defined criteria. The percentage of participants meeting the public health PA guidelines was calculated based on the American Cancer Society (ACS) [11]and the American College of Sports Medicine (ACSM)[13]. The guidelines suggest cancer patients engage in at least 150 min/week of moderate or 75 min/week of vigorous exercise[13]. Thus, we calculated “PA minutes” as moderate minutes plus two times the vigorous minutes. These PA minutes were then transformed into the following three categories: (1) inactive (no PA minutes), (2) insufficiently active (1–149 PA minutes), and (3) active ,meeting guidelines (≥150 PA minutes).

Questions 24–35: Physical Activity Preferences

Physical activity preferences were assessed through inquiries derived from previous research [7, 9, 10, 26, 27]. The initial query pertained to the patient's willingness to engage in an exercise regimen (yes/no/maybe). Participants were then asked about their preference regarding: the source of exercise instructions (oncologist/nurse/kinesiologist/no preference/other); the desired type of physical activity (aerobic exercise/strength training/balance training/flexibility training); the preferred method of receiving exercise instructions (face to face/via WeChat APP/brochure-pamphlet/online/no preference/other); the preferred exercise companions (nobody/family members/friends/a group/no preference/other); the preferred exercise location (at home/in a community/outdoors/no preference/other); the preferred time of day (morning/afternoon/evening/no preference); and the desired frequency (ranging from never to seven times per week). Furthermore, additional information was gathered regarding the preferred intensity level (mild/moderate/strenuous/no preference), supervision preference (unsupervised/supervised/no preference), and model of exercise program (home-based exercise/site-based exercise/no preference). Two open-ended questions were also included, wherein respondents were encouraged to list their top three preferred exercise activities for both winter and summer seasons.

Questions 36–52: The fear of exercise

In order to better understand the fear of exercise and physical activity among liver cancer patients, questions related to exercise phobia were extracted based on the Tampa Scale of Kinesiophobia TSK^[28]. It contains a total of 17 items, each with 4 scores: 1 (completely disagree), 2 (partially agree), 3 (somewhat agree), and 4 (strongly agree). The score range is between 17-68, and a total score >37 indicates a high level of fear towards exercise and physical activity, which is also known as exercise phobia. The higher the score, the greater the level of kinesiophobia. The TSK-17 has been widely used in research and clinical practice, particularly in evaluating the symptoms of kinesiophobia among chronic pain patients[29-31].

Statistical Analysis

The data was input and analyzed through Statistical Package for Social Sciences program (SPSS，version 26.0, IBM). Descriptive analyses are presented as means and standard deviations ，medians and IQR for continuous variables and frequencies and percentages for categorical variables. Associations between demographic and medical variables with the willingness to start a PA program (yes, maybe, and no) were examined using chi-square analysis. A P value less than 0.05 was considered statistically significant. Multivariable regression models were utilized to investigate factors associated with their willingness to participate with explanatory variables pre-selected in the chi-square analysis, which subsequently maximized goodness of fit.

Among the 642 liver cancer patients screened from electronic medical records of hospitalized patients, 319 met the inclusion criteria, with 71 refusing to participate in the survey. The most common reasons cited were lack of interest and time. Among the 248 who agreed to participate, 44 did not return the QEX, resulting in a final study sample of 204 . The flow diagram of participants is shown in Figure 1.

General and medical Characteristics

The participants’ mean age was 64.0 ± 8.9 years old, 166(81.4%) were males, 152(74.5%) were live in the city of Wuxi, 159(77.9%) were received the education up to 12 years, and overall, 189(93%) of participants were still on active treatment; with a median time since diagnosis of 13 (4, 33) months, and 33(16.2%) were at the advanced stage.

Physical activity level and behavior

Participants’ Physical activity levels are shown in Figure 2a. Results from the IPAQ-S survey showed that only 14.2% of individuals met the physical activity recommendations set by the ACS[11]. Moreover, 19.6% of liver cancer patients reported being physically inactive daily. Table 1 provides a representation of the mean frequency of vigorous, moderate, and walking activities as self-reported by participates. Patients reported mean frequencies of strenuous, moderate, and walking are shown in Table 1.

Table 1 Duration of different levels of physical activity in liver cancer patients (within the past week)

Physical activity	0min ~	10min~	30 min ~	60 min ~
Walking	38（18.1）	58（27.6）	89（42.4）	25（11.9）
Moderate	163（77.6）	38（18.1）	9（4.3）	0（0.0）
Strenuous	202（96.2）	5（2.4）	3（1.4）	0（0.0）

Physical activity Preferences

Willingness of participants in PA programs is illustrated in Figure 2b. Participants PA preferences are listed in Table 2. In total, 150 (73.5%) expressed their willingness (yes or maybe) to partake in a tailored PA program specifically designed for liver cancer patients. Participants who expressed willingness to participate in the program were asked about their preferences regarding PA. Among them, 75 (50%) favored receiving exercise instructions from an oncologist, while 32(21.3%) preferred instructions from a nurse and 18(7.2%) from a kinesiologist. The preferred method of receiving exercise instructions was through face-to-face interactions, chosen by 58 (38.6%), followed by the WeChat APP, chosen by 54 (36.0%). A significant portion of participants 74 (49.3%) preferred exercising alone. The favored model for exercise was home-based workouts, with 111 (74%) expressing their preference. As for the timing, the majority of patients favored exercising in the morning (36.7%) or evening (31.3%). Approximately half of the patients (50.7%) opted to engage in physical activity three to four times per week. Walking emerged as the most preferred activity both in summer and winter. Participants also indicated a preference for training at mild intensity (78%) or moderate intensity (22%). More than half of the participants (58.6%) favored an exercise program lasting between 10 and 30 minutes per session. Most of them (71.3%) expressed a preference for unsupervised exercise.

Table 2. Exercise preferences in cancer patients

Preference as Indicated by Responses to Questions	No.	%
Are you interested in engaging in a tailored exercise regimen designed for liver cancer patients? (204)
Yes	104	51.0
No	54	26.5
maybe	46	22.5
Who would you prefer to receive exercise instructions from? (150)
Oncologist	75	50.0
Nurse	32	21.3
Kinesiologist	18	7.2
No preference	23	15.3
How would you prefer to receive exercise instructions? (150)
Face to face	58	38.6
Via wechat APP	43	28.6
Leaflet	34	22.6
No preference	15	10.0
Where would you prefer to exercise? (150)
Home-based	111	74
Site-based	23	15.3
No preference	16	10.7
What time of day would you prefer to exercise? (150)
Morning	55	36.7
Afternoon	17	11.3
Evening	47	31.3
No preference	51	20.6
How would you prefer to exercise? (150)
Unsupervised	107	71.3
Supervised	23	15.4
No preference	20	13.3
Who would you prefer to exercise with? (150)
Alone	74	49.3
Family members	47	31.3
Friends	17	11.3
A group	10	6.7
No preference	2	1.3
How often would you prefer to exercise? (150)
Once to Twice a week	18	12
Three to four times a week	76	50.7
Five to six times a week	35	23.3
Every day	16	10.7
No preference	5	3.3
What exercise intensity would you prefer? (150)
Mild	117	78.0
Moderate	33	22.0
Strenuous	0	0
No preference	0	0
How long would you prefer to exercise every time? (150)
0-10 minutes	3	2.0
10-30 minutes	88	58.6
30-60 minutes	58	38.7
No preference	1	0.7

Univariate analysis of Demographic and medical variables associated with willingness to participate in PA programs.

Demographic and medical variables stratified by the willingness to participate in the exercise program are set out in Table 3. Patients are divided into three groups based on their willingness to participate in PA programs: yes, maybe, and no. Chi-square analysis indicated significant differences among the three groups of patients in terms of sex, place of residence, BMI, Child-Pugh score, time since diagnosis, physical activity level，and TSK-17 score (all P<0.05).

Table 3 General and medical characteristics of 204 liver cancer patients according to willingness to participate in a specifically designed PA program.

	Willingness to Participate				𝜒 value	p value
	All n (%)	Yes n (%)	Maybe n (%)	No n (%)	𝜒 value	p value
Age (years)
<65	72(35.3)	33(31.7)	17(37.0)	22(40.7)	1.335	0.513
≥65	132(64.7)	71(68.3)	29(63.0)	32(59.3)
Sex
Female	38(18.6)	22(21.2)	3(6.5)	13(24.1)	6.487	0.039
Male	166(81.4)	82(78.8)	43(93.5)	41(75.9)
Education
Up to age 12 years	159(77.9)	78(75.0)	39(84.8)	42(77.8)	1.776	0.411
Beyond age 12 years	45(22.1)	26(25.0)	7(15.2)	12(22.2)
Residence
In wuxi	152(74.5)	85(81.7)	24(52.2)	43(79.6)	15.684	<0.001
Outside city	52(25.5)	19(18.3)	22(47.8)	11(20.4)
Perceived income adequacy
Inadequate	63(30.9)	26(25.0)	17(37.0)	17(37.0)	3.439	0.179
adequate	141(69.1)	78(75.0)	29(63.0)	29(63.0)
Body Mass Index
Underweight	12(5.9)	3(2.9)	1(2.2)	8(14.8)	9.376	0.044
Normal weight	119(58.3)	60(57.7)	28(60.9)	31(57.4)
Overweight	73(35.8)	41(39.4)	17(37.0)	15(27.8)
Disease status
Early	171(83.8)	89(85.6)	39(84.8)	39(84.8)	0.967	0.616
Advanced	33(16.2)	15(14.4)	7(15.2)	7(15.2)
Child-pugh
A level	105(51.5)	62(59.6)	17(37.0)	26(48.1)	9.808	0.028
B level	94(46.1)	38(36.5)	29(63.0)	27(50.0)
C level	5(2.5)	4(3.8)	1(1.9)	1(1.9)
Time from diagnosis
≤12 Month	89(43.6)	36(34.6)	25(54.3)	28(51.9)	7.069	0.029
>12 Mouth	115(56.4)	68(65.4)	21(45.7)	26(48.1)
PA level
Inadequate active	175(85.8)	79(76.0)	43(93.5)	53(98.1)	17.231	<0.001
Active	29(14.2)	25(24.0)	3(6.5)	1(1.9)
TSK-17
≦37	38(18.6)	25(24.0)	9(19.6)	4(7.4)	6.520	0.038
>37	166(81.4)	79(76.0)	37(80.40	50(92.6)

PA, Physical activity

Multivariable logistic regression model of associations of characteristics of liver cancer patients with willingness to participate in an PA program.

Table 4 elucidates the associations between demographic and medical variables pertaining to exercise behavior and the willingness of cancer patients to participate in an exercise program. Multivariable logistic regression model indicated that the following factors independently significantly influenced the willingness to PA program. Patients whose time since diagnostic beyond 12 months were more inclined to participate (OR:1.905, 95% CI: 1.017 to 3.567). Patients whose current physical activity levels met the recommendations set by the American Cancer Society (ACS) were significantly more likely to participate (OR: 3.961, 95% CI: 1.159 to 13.538). Patients residing outside the city exhibited a decreased willingness to participate compared to those living in the city of Wuxi (OR:0.424, 95% CI: 0.203 to 0.885). Patients with higher scores on the Tampa Scale of Kinesiophobia were less likely to engage in the exercise program (OR: 0.889, 95% CI: 0.831 to 0.950).

Table 4 Multivariable logistic modeling of associations of characteristics of liver cancer patients with willingness to participate in an exercise program.

		B value	Standard error	Wald value	P value	OR	95% CI for OR
							Lower	Upper
Age	<65*	0.496	0.337	2.165	0.141	1.642	0.848	3.180
	≥65
Sex	Female*	-0.696	0.408	2.913	0.088	0.498	0.224	1.109
	Male
Time since diagnostic	≤12 Month*	0.644	0.320	4.051	0.044	1.905	1.017	3.567
	>12 Mouth
Place of residence	In wuxi*	-0.857	0.375	5.217	0.022	0.424	0.203	0.885
	Outside city
PA level	Inadequate*	1.377	0.627	4.820	0.028	3.961	1.159	13.538
	Adequate
TSK-17	Original value	-0.118	0.034	11.948	0.001	0.889	0.831	0.950
Constant		5.212	1.661	9.845	0.002	183.500

OR Odds ratio; PA, Physical activity; CI, Confidence interval; TSK, Tampa Scale of Kinesiophobia;

* Reference

According to the survey, merely 14.2% of liver cancer patients med to the PA guidelines proposed by the American Cancer Society (ACS)[11]. Previous research studies indicated that the percentage of cancer patients meeting the required PA levels was 16%∽85%.[6]. Considering the impact of PA on a decreased physiological reserve associated with a low QoL, poor clinical outcome, mortality, highlighting the importance of designing PA programs specifically for liver cancer survivors.

Approximately 73.4% of patients expressed their willingness to enroll in a PA program tailored for liver cancer patients. Similar findings have been reported in other cancer studies.[7-10, 17, 26]. This is important because it supports the cancer patients’ desire for an exercise service. Several socio-demographic characteristics were associated with the willingness to participate in a PA program. Willingness didn’t decrease with age, also in adjusted model, and this was contrary to previous studies[7, 8, 17]. The reason for this could be that despite being older and having reduced physical capabilities and comorbidities, elderly individuals may still desire to improve their health status through physical activity. We found that, even among the older patients’ study[9, 10], more than two-thirds expressed they might be interested in taking part in a PA program. Patients lived outside city were more decline to participate. This may be related to the limited resources available for care, health literacy, and education among liver cancer patients living outside the urban areas. The ACS has noted that research on disparities in cancer survivorship health outcomes has primarily focused on race, ethnicity, and rural populations[11]. Patients who med the recommendation of ACS guidelines were more willing to participate in an exercise program. A possible explanation is that those who have already done more physical exercise perceive the benefits better and are therefore more ready to improve or increase their level [7, 32].

When considering psychological factors associated with physical activity barriers, we utilized the TSK-17 score. Our study showed that liver cancer patients who scored >37 on the TSK-17 demonstrated a lower tendency to engage in PA programs. Multivariable regression analysis ajusted for age and sex identified that the TSK-17 score independently served as a significant predictor of willingness to engage in physical activity programs. Liver cancer survivors are often accompanied by cirrhosis, often resulting in liver function deterioration, varices, ascites, and other complications. This limits the patient’s physical activity and promotes a sedentary lifestyle. Exercise induced hepatic vein pressure gradient increase has been a hot topic among hepatologists[33]，Patients with fear of physical activity are hesitant to engage in PA due to concerns about impaired liver function and increased risk of variceal bleeding. However, an increasing body of research has demonstrated that exercise is safe and effective for patients with advanced liver disease. This highlights the importance for healthcare providers to enhance their patient education efforts by addressing disease-specific knowledge gaps and alleviating psychological concerns.

The results of the survey showed that participants preferred to receive exercise instruction from their oncologist, which differs from previous studies where an exercise expert, such as a kinesiologist, was preferred[6]. This may be due to the lack of exercise specialists available for patients at Jiangnan University Affiliated Hospital. Another possible explanation is the trusting relationship that is built between the patient and their oncologist throughout their cancer journey. Participants had diverse preferences for receiving physical activity guidance, with similar proportions preferring face-to-face, via WeChat APP, and Leaflets. This suggests that providing patients with various guidance methods can meet the needs of different patients and complement the advantages and disadvantages of different education methods.

In line with previous studies[6, 7, 9, 10, 26, 34], Nearly all studies indicated a specific preference towards walking as a preferred mode of PA, suggesting that programs for cancer survivors should be designed around walking to increase interest in participation. Walking programs have been shown to be effective in managing treatment side effects and improving physical function in people with cancer[35, 36] . Walking is a safe, adaptable, and effortless form of exercise that does not require any special skills. Additionally, walking can be performed in a variety of environments, making it easily accessible and appropriate for various groups of people, regardless of age, gender, ethnicity, education, or income level, and does not require expensive equipment. Moreover, research shows that walking helps to break down social barriers for people from different socio-economic backgrounds [37] .

In contrast to other studies[27, 38, 39], the findings of the present study suggest that the preferred exercise intensity is mild. This may be related to the concern among liver cancer patients that high-intensity physical activity could lead to risks such as worsened liver function and bleeding from varices. Current exercise guidelines for cancer patients suggest engaging in at least moderate exercise[13]. However, choosing a mild intensity may be a favorable starting point for initiating an exercise program, especially for those who are physically deconditioned, and can be gradually increased to moderate and vigorous intensity. Several reviews have shown that moderate-to-vigorous exercise intensity, but not mild intensity, is effective in managing cancer side effects and improving physical function. The current findings emphasize the importance of informing cancer patients and their caregivers about the safety of moderate and vigorous intensity exercise.

In our study, most participates express a preference for home-based and unsupervised programs. This finding contrasts with investigations on mixed[7] and lung[27] cancers but is in line with other studies on head and neck[40] cancer. The reason for this may be that most participants prefer engaging in mild physical activity, within their own comfortable and safe range, where they can control over their PA. However, a meta-analysis conducted by Buffart et al.[41] on the effects of PA on quality of life and physical function found that supervised PA had double the effect size of unsupervised PA. This suggests that a trainer's greater guidance, access to equipment, and adherence to protocol may be a contributing factor. Therefore, developing home-based interventions or gradually transitioning to home-based PA programs may be beneficial for cancer survivors who prefer such programs. It is important to distinguish between unsupervised and home-based programs, as the latter can offer motivational support, guidance, and counseling through m-health and e-health interventions[42, 43] . Nearly half of liver cancer patients choose to exercise alone, while the remaining half opt to exercise with a companion (such as a family member, friend, or group activity). The vast majority of our participants are male, which may explain the results.

This study seems to be the first to investigate the factors that influence PA preferences in liver cancer patients prior to their participation in PA intervention programs. The results provide valuable information for the development of future exercise programs. The use of self-reported QEX allowed for the collection of a large amount of data in a quick and cost-effective manner, without placing a heavy burden on the respondents. Another strength lies in the collection of information on reasons why some individuals chose not to participate in the study.

It is important to acknowledge the limitations of this study, such as the fact that the QEX information was self-reported, and thus susceptible to various sources of bias. The patient information leaflet given during recruitment only provided a basic overview of the study without any recommendations or guidelines, which may have influenced the responses given. Furthermore, selection bias may have played a role, as those who agreed to participate in the survey may have been more interested in exercise than non-participants. These factors should be taken into consideration when interpreting the study's findings. The QEX questionnaire does not gather data on participants' pre-diagnosis exercise and physical activity, which restricts its capacity to investigate potential relationships with other determinants of current exercise behavior. The survey provides clinically relevant information that can aid in the design of personalized interventions aimed at encouraging sufficient exercise and physical activity among liver cancer patients.

Our exploratory survey serves as a necessary first step in improving compliance with physical activity programs among patients. This is especially important in countries like China, where liver cancer is prevalent and research on PA among liver cancer patients is scarce, with limited understanding of factors such as family environment and social support. While most individuals are willing to exercise, only a small percentage of patients possess sufficient physical capacity to do so. These findings underscore the urgency of promoting personalized PA intervention programs among liver cancer patients in China.

Acknowledgements We thank patients and institutions for participating in the study.

Authors’ contributions H.C. conducted the literature search, collected and analyzed the data, and wrote the manuscript. H.Z., BW., H.L., and S.Z. conducted the literature search and collected and analyzed the data. Y.G. and Z.D. contributed to the conception and design of the study and the interpretation of data and critically reviewed the manuscript. J.Y. conceptualized and designed the study, supervised the survey team and data analysis, participated in data analysis, contributed to the discussion, reviewed and edited the manuscript, and provided critical data interpretation. All authors read and accepted the final manuscript.

Data availability Data and materials used in this work are available from the corresponding author upon request.

Ethics approval and consent to participate Ethical approval for the current study was obtained from the Ethics Committee of Jiangnan University with reference number JNU20221201IRB14. All study procedures were performed in accordance with the latest revision of the Helsinki Declaration. After being informed about the study content, each of the patients who agreed to participate provided verbal informed consent to confrm their willingness to participate. The Ethics Committee of Jiangnan University approved only verbal informed consent. The reason for verbal consent is that participants were only required for the interview and were not subjected to any harm as long as their privacy was kept confidential. The authors confirmed that all the methods were performed following the relevant guidelines and regulations.

Conflicts of interest The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.

Funding This research was funded by a grant from Wuxi Science and Technology Development Fund Project (N20201003); Wuxi "Double Hundred" Top Medical and Health Talents Training Program (BJ2020045); Wuxi Translational Medicine Research Institute (LCYJ202218)

Authors and Afliations

Haiyan Chen^1,2, Huimin Zhou^1,2, Bo Wu^1,2, Hanxiao Lu^1,2, Zhixia Dong², Shuo Zhang², Yuanlong Gu^1,2, Jun Yang^1,2*

¹ Department of Nursing, Jiangnan University, Wuxi, Jiangsu, China

² Department of Gastroenterology and Hepatology, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China

Haiyan Chen[email protected]

Huimin Zhou [email protected]

Bo Wu: [email protected]

Hanxiao Lu:[email protected]

Zhixia Dong: [email protected]

Shuo Zhang: [email protected]

Yuanlong Gu: [email protected]

Jun Yang: [email protected]

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No competing interests reported.

Physical activity levels, willingness, and preferences in liver Cancer Patients: A Cross-Sectional Study

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Abstract

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Introduction

Materials and Methods

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