To the best of our knowledge, this is the first large study to investigate changes in exercise behaviors among cancer patients during the first 6 months of the COVID-19 pandemic as well as characteristics associated with these changes. One-third of our study population reported to have decreased the amount of regular exercise. Our results also indicate that age, employment status, overall health status, alcohol consumption, current patient status, and psychosocial factors were associated with changes in exercise behaviors during the pandemic.
A reduction in exercise is especially concerning in the cancer population given the strong evidence of beneficial effects of physical activity on survivorship (12–16, 19, 35). Physical activity before and after cancer diagnosis has been shown to have substantial health benefits for cancer patients (12–16, 19, 35). Physical activity not only reduces the risk of cancer but can also improve cancer outcomes, including survival and recurrence. (12–16, 19, 35). Further, physical activity enhances overall quality of life and physical function particular among individuals with cancer, and may improve other potential comorbidities including diabetes, cardiovascular, or respiratory diseases (19). Although not explicitly asked in this study, challenges in accessing exercise facilities, being at high risk of having poor outcomes if exposed to COVID-19 infection, or finding motivation to exercise due to stay-at-home policies may have contributed to the substantial decrease in exercise activities observed in this study.
Our study provides further support for prior research before the pandemic highlighting the barriers to exercise and determinants of exercise adherence among cancer survivors (36, 37). Older cancer survivors often engage in less activity due to underlying health conditions, a higher prevalence of overweight and obesity, cancer treatment-related side effects such as fatigue and pain (37). Among cancer patients, adherence to exercise interventions does not appear to be influenced by sex, although the data remains inconclusive (36). However, our results indicate that response to the pandemic with respect to increased physical activity was higher among female patients compared to those whose physical activity decreased. In alignment with previous studies showing that employed individuals spend more time in moderate and vigorous physical activity (38, 39), full-time employed patients in our study population were more likely to increase their activity levels since the start of the pandemic. Greater opportunities to workout while working from home and less time spent commuting may explain this observation. On the contrary, unemployed patients may be retired and older or may have lost job due to the pandemic and, hence, less active. Consistent with prior research,(40, 41) urban patients in our study experienced more changes in their exercise habits due to the pandemic, potentially due to stay-at-home policies, closure of gyms, or more time to workout (42, 43).
Our study indicates that patients diagnosed with lung cancer or hematologic neoplasms were more likely to increase exercise during the pandemic, while patients diagnosed with gastrointestinal cancers and melanoma were more likely to decrease exercise than increase or maintain it. This aligns with studies conducted before the pandemic showing reduced engagement in physical activity among patients with gastrointestinal cancer (44, 45). Melanoma patients are also more likely to avoid outdoor activities to minimize sun exposure (46), which may explain reduced exercise levels due to closure of gyms with outdoor exercise being the only alternative. Our data suggest that patients with stage IV disease tend to exercise more. Exercise may be a mechanism for these patients to cope with the high burden of treatment- and disease-related side effects. Our data also showed that patients who were currently undergoing active cancer treatment were more likely to decrease exercise. This may be confounded since patients who are currently undergoing treatment or recently completed treatment are likely to experience treatment-related side effects, impairments from surgical intervention, and may be more prone to infections due to weakened immune system and may want to avoid outdoor activities.
Patients following other healthy lifestyle behaviors such as never drinking alcohol or decreasing alcohol consumption during the pandemic were more likely to exercise more, which is consistent with previous studies (47). Individuals who fall into an overall ‘healthier’ lifestyle cluster considering smoking, nutrition, alcohol, and physical activity, are generally more active (47). Overall, our data suggest that the pandemic contributed to the factors that have been previously identified as barriers to exercise, resulting in less exercise during the pandemic among a significant proportion of cancer patients and survivors.
Strong evidence supports exercise as a coping mechanism for side effects of cancer, its treatment, and related behavioral health challenges including anxiety, depression, fatigue, and sleep difficulties (48–50). Research also shows that individuals with underlying mental health problems, perceived stress, or financial hardship engage in less physical activity (51–53). The pandemic has caused the majority of individuals to experience increased levels of stress and anxiety as well as financial difficulties due to loss of employment, income, or health insurance (8, 54). In addition, social distancing policies and other restrictions to prevent the spread of the virus have reduced the ability to cope with underlying mental health conditions. A recent study reported that individuals who remained active or increased their activity levels during the pandemic have done so to maintain their mental health (55). In contrast, mental health conditions associated with the pandemic have emerged as barriers to exercise (55). Our results confirm these findings within the cancer population. In particular, patients who felt lonely, had less social interactions, were financially stressed, and experienced perceived stress in terms of difficulties piling up were more likely to exercise less and less likely to engage in more exercise. These results elucidate the need to screen for mental health challenges faced by cancer survivors during the pandemic and promote psychosocial programs that address unique needs and challenges within this population.
This study has several strengths and limitations. Exercise habits were self-reported and may be subject to recall bias. However, given the timeliness of the pandemic, the conscious perception of changes in life experienced by many, and prospective design of the study, we assume that patients can more easily recall any behavioral changes. Survey responses may have been biased by the type of survey (in person, phone, electronically). The majority of the study population was White, non-Hispanic/Latino, and from Utah. Thus, the generalizability of our results may be limited and not applicable to those with different racial and ethnic backgrounds, or those from other states who may have had different COVID-19 state-wide policies. However, our study population included a significant proportion from rural residents (26%) making the results more applicable for other states with similar urban-rural proportions. The response rate was moderate and may have introduced selection bias.
The pandemic has impacted everyone’s lives in many ways including changes in health behaviors. Health behaviors such as being physically active are even more important for immune compromised populations like cancer survivors. Our results indicate that many cancer patients and survivors reduced their exercise during the first 6 months of the pandemic. This was more common among patients who had poor health, disruptions to daily life, reduced social interactions, and increased levels of psychosocial stressors such as loneliness and financial stress. This study identifies risk factors for changes to physical activity among cancer patients and survivors as well as highlights targets for future interventions to prevent reduced physical activity and promote increased exercise.