Introduction

There is growing evidence demonstrating that physical activity (PA), be it aerobic, resistance (strength) or a combination thereof, produces physical and psychosocial benefits [7, 11, 16] that counteract many of the adverse effects of common cancer treatments [8, 17]. Such research has led professional organisations, including the American Cancer Society, to develop position statements outlining the importance of PA and recommending that physically inactive patients become more active. Specifically, guidelines recommend that cancer patients perform 150 min of aerobic and 60 min of resistance training per week [16].

Health professions (e.g. general practitioners, oncologists and oncology nurses) are expected to provide high-quality, evidence-based education and counselling to their patients in relation to the potential risks and benefits of cancer screening and/or treatment [20]. However, studies have shown that health professionals report numerous barriers preventing them from discussing PA with their patients and, most importantly, assisting them to make the necessary behavioural changes to accommodate recommended PA levels [5, 6, 18, 21]. We offer a narrative review of the relevant empirical work and propose practice recommendations for health professions, hospitals and universities for improving the promotion of PA to cancer patients.

Discussing Physical Activity with Cancer Patients

A recent study revealed that most cancer patients do not adhere to the PA guidelines of the American Cancer Society, and many are less active than their age-matched, non-cancer peers [10]. In light of research demonstrating the benefits of PA for cancer patients, it is clear that health professionals have a duty of care to more regularly discuss PA during their consultations. There is now considerable research that has examined the determinants of cancer patients’ PA levels in an attempt to investigate possible ways to increase their PA [9, 19, 13, 14]. Surprisingly, very little of this research has focused on the role of the health professional in supporting the PA behaviour of the patients [18, 15]. A summary of the main issues facing cancer patients post-diagnosis, the benefits of regular PA and the possible role of health professionals in assisting their patients becoming more physically active is summarised in Fig. 1.

Fig. 1
figure 1

Possible role of health professionals in promoting physical activity and improving outcomes for cancer patients

Full size image

Physical Activity Promotion Practices and Determinants of Health Professionals

Promotion of PA by health professionals has been shown to significantly improve health, physical and psychosocial outcomes for a variety of patient groups [12, 3]. The promotion of PA by a health professional to their cancer patients has demonstrated significant increases in patients’ PA levels, energy expenditure, aerobic fitness, muscular strength and quality of life as well as reduction in the number of barriers to PA [2, 4]. Jones et al. also reported significantly larger increases in PA levels if patients remembered the nature of the PA advice from the health professional [4]. However, relatively little is known about the PA promotion practices of health professionals and the factors that influence this promotion to their cancer patients [5, 6, 18, 21].

In relevant work, studies have reported that up to 40 % of health professionals only promote PA to the patients they feel would benefit from being more physically active, rather than promoting PA as a standard part of usual care for all patients [5, 6, 18, 21]. While these results are somewhat encouraging, the survey response rates were 14–62 % which may indicate a potential response bias, whereby health professionals who regularly promote PA to their patients may have more likely completed the surveys [5, 6, 18, 21]. These findings, therefore, should be interpreted with some caution. Nonetheless, the surveys revealed that many health professionals were aware that PA could reduce the physical side effects of treatment, lower the risk of developing other chronic conditions and improve physical function, mental health and quality of life. Of the health professionals who promoted PA, they also endorsed evidence-based aerobic activities such as walking for weight loss, cardiovascular health, improved mental health and quality of life [16]. Considerably fewer promoted resistance training as a form of PA to their patients, despite resistance training being more beneficial than aerobic activity in counteracting the substantial declines in muscle mass, strength and physical performance seen with common cancer treatments [7]. Most importantly, the survey data revealed that there are many barriers to PA promotion for these health professionals. For example, health professionals thought that other professionals were promoting PA to the patients, reported lacking the time needed for such discussions during patient consultations and indicated that they lacked the required knowledge in PA promotion [5, 6, 18, 21]. These barriers appeared quite similar to the concerns reported by 236 cancer patients about their regular consultations with their health professionals [1]. Brandes et al. [1] reported that patients indicated their primary barriers to discussing their concerns with health professionals related to the health professionals’ behaviour (e.g. a lack of empathy, not inviting the patients’ to identify their concerns and an inability to provide accurate information) as well as the consultation environment (e.g. lack of time to listen to concerns).

Taken together, these findings warrant health professionals being more proactive in the promotion of PA to their patients. This may be achieved by health professionals initiating such discussions with their patients, attentively responding to questions from their patients and assisting their patients develop strategies to overcome any barriers that may make regular PA difficult. However, there is still much to learn about the primary determinants influencing health professionals’ promotion of PA to their patients. If these determinants are better understood, behavioural interventions using evidence-based behavioural change models can assist health professionals’ in promoting healthy behaviours like PA and result in significantly improved outcomes for their patients.

Possible Ways to Improve the Physical Activity Promotion Practices of Health Professionals

When discussing PA and other healthy behaviours with their patients, it is recommended that health professionals utilise evidence-based behavioural change practices [3]. In an extensive review of approaches to improve patient-physician communication, Woulda and van de Weil proposed using an adapted version of the reflective-impulsive model of social behaviour [22]. While Woulda and van de Wiel [22] acknowledge that the full implementation of the reflective impulsive model requires considerable effort, they recommended its use as a benchmark for improving patient-physician communication and identified five key learning objectives and teaching methods for communication education. Specific examples of how health professionals may use this approach when discussing PA with their cancer patients are highlighted in Table 1.

Table 1 Learning objectives for improving health professional-patient communication regarding physical activity: a proposed approach based on the reflective impulsive model of social behaviour [22]
Full size table

As alluded to in Table 1, it is understood that the behaviour, knowledge and/or work environment of the health professional may act as facilitators or barriers to effective patient-centred communication about PA. Many health professionals may identify aspects of their own behaviour or work environment that would act as barriers to effective PA communication with their patients; therefore, we recommend the development of referral networks, whereby patients are referred to specialists in PA (e.g. exercise physiologists or physiotherapists or psychosocial/behavioural counselling).

The reflective impulsive model [22] also has major implications for training models used by universities and hospitals. It is recommended that universities and hospitals provide a series of educational experiences which progressively develop the clinical communication skills of their students, interns and staff [22, 23]. An overview of how this may be applied to improving PA promotion and counselling for cancer patients is provided in Table 2.

Table 2 Teaching and assessment methods of clinical communication skills with respect to patient physical activity: a proposed approach for universities and training hospitals based on the reflective impulsive model of social behaviour [22, 23]
Full size table

Conclusions

Health professionals appear interested in promoting PA to their patients, but evidence suggests that they experience several barriers to this activity. It is vital that health professionals use evidence-based behavioural change approaches in promoting the proven benefits of PA during their patient consultations. Universities, hospitals and accreditation bodies can all play important roles in assisting health professionals achieve this goal.

More research is required to continually improve practice in this area. Relevant studies may examine the following: patient benefits obtained through behavioural theory-based PA promotion programs led by primary cancer clinicians such as oncologists, the determinants and current PA promotion practices of a wider variety of health professionals, and how differences in health professional and patient characteristics may impact PA promotion and patient outcomes.

Based on the strong evidence for the benefits of PA for cancer survivorship [7, 11, 16], health professionals, universities, hospitals and national health-care accreditation organisations are encouraged to consider the conversational value and implementation processes of PA promotion as part of their usual care for all cancer patients, not just those for those who are subjectively assessed by health professionals to need it. We recommend that evidence-based practice educational modules include discussions on the benefits of PA as well the behavioural change models that may best increase PA levels for cancer patients. Hospitals should examine ways they can better encourage their primary cancer clinicians to work more collaboratively with PA and counselling specialists in this endeavour. This may be achieved by hospitals developing improved PA resources and/or referral pathways to cancer-specific PA programs that are more accessible to patients. Collectively, these approaches may improve PA promotion by health professionals and result in improved outcomes for patients [14, 19].