Systematic review

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Effect of exercise interventions on hospital length of
stay and admissions during cancer treatment: a
systematic review and meta-­analysis
David Mizrahi ‍ ‍,1,2 Jonathan King Lam Lai,3,4 Hayley Wareing,3 Yi Ren,3
Tong Li ‍ ‍,1,3 Christopher T V Swain ‍ ‍,5,6 David P Smith ‍ ‍,1 Diana Adams,7
Alexandra Martiniuk ‍ ‍,1,8,9 Michael David1,10

► Additional supplemental ABSTRACT

material is published online Objective To assess the effect of participating in an WHAT IS ALREADY KNOWN ON THIS TOPIC
only. To view, please visit the ⇒ Exercise in patients diagnosed with cancer
journal online (http://d​ x.​doi.​ exercise intervention compared with no exercise during
org/1​ 0.​1136/​bjsports-​2023-​ cancer treatment on the duration and frequency of has been shown to improve quality of life,
107372). hospital admissions. functional capacity, cardiorespiratory fitness,
Design Systematic review and meta-­analysis. reduce symptom burden and lower the risk of
For numbered affiliations see recurrence and mortality.
Data sources MEDLINE, EMBASE, PEDro and Cochrane
end of article.
Central Registry of Randomized Controlled Trials. ⇒ Numerous oncology organisations
Eligibility criteria for selecting internationally now endorse exercise during
Correspondence to
Dr David Mizrahi, The University studies Randomised studies published until August and after cancer treatment.
of Sydney, Sydney, Australia; 2023 evaluating exercise interventions during ⇒ It is unknown whether participating in a
d​ avid.​mizrahi@​sydney.​edu.a​ u chemotherapy, radiotherapy or stem cell transplant structured exercise intervention during
regimens, compared with usual care, and which assessed chemotherapy, radiotherapy or stem cell
Accepted 12 October 2023
Published Online First hospital admissions (length of stay and/or frequency of transplant regimens reduces the duration and
21 November 2023 admissions). frequency of hospital admissions.
Study appraisal and synthesis Study quality was WHAT THIS STUDY ADDS
assessed using the Cochrane Risk-­of-­Bias tool and
Grading of Recommendations Assessment, Development ⇒ This systematic review and meta-­analysis
and Evaluation assessment. Meta-­analyses were evaluate the evidence regarding the association
conducted by pooling the data using random-­effects between participating in exercise interventions
models. during cancer treatment and reductions in the
Results Of 3918 screened abstracts, 20 studies duration and frequency of hospital admissions.
met inclusion criteria, including 2635 participants ⇒ There was a small but significant effect size in a
(1383 intervention and 1252 control). Twelve studies pooled analysis that structured exercise during
were conducted during haematopoietic stem cell treatment reduced hospital length of stay by
transplantation regimens. There was a small effect size in 1.40 days compared with usual care.
a pooled analysis that found exercise during treatment ⇒ Structured exercise during cancer treatment
reduced hospital length of stay by 1.40 days (95% CI: was demonstrated to be safe, and contributed
−2.26 to −0.54 days; low-­quality evidence) and lowered to an 8% lower rate of hospital admission.
the rate of hospital admission by 8% (difference in
proportions=−0.08, 95% CI: −0.13 to −0.03, low-­
quality evidence) compared with usual care. interventions that reduce complications from treat-
Conclusion Exercise during cancer treatment can ment are warranted.
decrease hospital length of stay and admissions, Different cancer treatments have varying levels of
although a small effect size and high heterogeneity supportive care needs which can impact the risk of
limits the certainty. While exercise is factored into some repeated and prolonged hospital stays. For example,
multidisciplinary care plans, it could be included as haematopoietic stem cell transplantation (HSCT) is
standard practice for patients as cancer care pathways a common treatment for haematological malignan-
evolve. cies in adults and children.4 HSCT typically requires
staying in a single-­bed isolation room for 4–6 weeks
due to the risk of bleeding complications and infec-
tion caused by immunodeficiency and neutropenia.5
INTRODUCTION Treatments including surgery, chemotherapy, radio-
© Author(s) (or their
employer(s)) 2024. No In 2020, there were approximately 19.3 million therapy and immune or targeted therapies also carry
commercial re-­use. See rights new cancer diagnoses worldwide.1 Cancer treat- a risk of hospital admission to manage common
and permissions. Published ment typically involves prolonged regimens that side effects such as dyspnoea, pain, cachexia and
by BMJ. can result in extended hospitalisation due to adverse fatigue.6 Repeated and prolonged hospitalisation
To cite: Mizrahi D, treatment-­ effects and reduced physical function.2 remains a significant physical, psychosocial, logis-
Lai JKL, Wareing H, The number of patients with cancer requiring tical and economic burden for patients, caregivers
et al. Br J Sports Med systemic therapies is projected to increase by 53% and healthcare systems. Lengthy periods of hospi-
2024;58:97–109. from 9.8 million in 2020 to 15 million in 2040,3 so talisation can disrupt the rest–activity cycle with

Mizrahi D, et al. Br J Sports Med 2024;58:97–109. doi:10.1136/bjsports-2023-107372    1 of 14

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associated physical deconditioning and sleep deprivation, while the hospital length of stay and admissions rate for patients with
also increasing the risk of falling, infections,7 impeding quality cancer undergoing HSCT, chemotherapy and/or radiotherapy
of life (QoL),8 alongside reducing satisfaction with care.9 The treatment regimens, with secondary aims examining specific
physical deconditioning from extended sedentary periods, which exercise parameters and by age group.
can cause fatigue, muscle wasting and reduced physical function
can further worsen QoL.10 METHODS
Hospital length of stay for patients with cancer varies by age, Search strategy and selection criteria
cancer type, insurance, treatment, comorbidity and country.11 In This systematic review was conducted in accordance with the
a high-­income country such as Australia in 2019–2020, there Cochrane Collaboration methods for systematic reviews,27 and
were 1.3 million cancer-­related hospitalisations, accounting for reported according to the Preferred Reporting Items for System-
one in nine of all hospitalisations, with the age-­standardised atic reviews and Meta-­Analyses checklist (online supplemental
admission rate increasing by 20% in the past 20 years.12 13 In the table 1).28 The review protocol was registered with PROSPERO
USA in 2017, the average duration for adults who were admitted (2022 CRD42022309639). Electronic database searches using
to hospital principally for their cancer was for 6.5 days.14 A combinations of keywords for ‘cancer’, ‘treatment’, ‘exer-
population-­ wide analysis in a middle-­ income country such cise’ and ‘hospitalization’ were undertaken in MEDLINE via
as Brazil found that patients with breast, prostate, colorectal, PubMed, EMBASE, Cochrane Central Register of Controlled
cervix, lung and stomach cancer in 2010–2014 spent a median Trials and PEDro (full search details are shown in online supple-
of 6 days in hospital during their first year after diagnosis.15 For mental table 2). The initial search included studies published in
patients treated for advanced cancers or haematological malig- peer-­reviewed journals from inception to 23 March 2022. All
nancies, the hospital length of stay is typically prolonged to 29 databases were searched again on 9 August 2023 to ensure the
and 26 days, respectively.16 17 Extended and repeated hospital articles included in this manuscript were current prior to publi-
stays can be costly for healthcare systems and individual payers, cation. No additional eligible studies identified between March
with the average cost of US$3400 per day.14 A recent system- 2022 and August 2023. Reference lists of relevant reviews were
atic review found no hospital-­initiated intervention (eg, clinical manually searched for any additional articles which were not
pathways, multidisciplinary care, case management, hospitalist identified in the database searches.
services) exhibited significantly reduced hospital length of stay
across high-­risk populations.18 However, this systematic review
did not include any studies incorporating exercise as an interven- Eligibility criteria
tion. Therefore, appraising the evidence around the effectiveness The Participant, Intervention, Comparator and Outcome frame-
of exercise-­based interventions in reducing hospital length of work29 was used to organise the inclusion criteria. The inclu-
stay and admissions is critical among patients undergoing cancer sion criteria included studies encompassing: (1) patients with
treatment who may experience reduced physical function, and adult or childhood cancer of any age, cancer type and disease
numerous side effects and comorbidities.6 stage, (2) undergoing cancer treatment regimens including
In the past two decades, physical activity (ie, any movement chemotherapy, radiotherapy or stem cell/bone marrow trans-
resulting in energy expenditure, such as leisure-­time activities) plant as individual therapy modality or combined regimens,
and exercise (ie, planned and structured physical activity with (3) randomised controlled trials (RCTs) which implemented
the aim to improve fitness) have become increasingly recognised an exercise intervention (ie, repeated bouts of exercise) during
as an important intervention for patients with cancer to engage the period of the cancer treatment regimen (eg, chemotherapy
in during and following treatment.19 Leading oncology organi- protocol), be it aerobic-­based, resistance-­based or mixed, which
sations now recommend incorporating regular aerobic and resis- could be delivered as a supervised in-­hospital intervention by an
tance exercise into standard practice during and after treatment, exercise professional or other member of the medical team, or
however the optimum dose and intensity recommended during an unsupervised intervention where a programme is created for
treatment is still unknown.20 21 For patients with more complex the participant to complete by themselves in hospital or at home,
medical attention, such as those with advanced cancer, exercise or a combination, compared with a usual care control group and
has been evidenced to be feasible, safe and beneficial.22 Exer- (4) studies assessing the hospital length of stay and/or number of
cise in patients with cancer has been shown to improve QoL, hospital admissions. Studies were included when interventions
functional capacity, cardiorespiratory fitness, reduce symptom other than exercise were also applied as part of the study (eg,
burden (eg, fatigue) and modulate systemic inflammation.23 24 education, meditation, nutritional interventions), and studies
Furthermore, epidemiological analyses show that patients with published in any language were permitted. Single-­arm and non-­
cancer with higher doses of moderate-­ to-­
vigorous physical randomised studies, systematic reviews, case studies and confer-
activity have a reduced risk of cancer recurrence and mortality.25 ence abstracts were excluded.
Patients with reduced cardiorespiratory fitness before treatment
have been shown to have lower chemotherapy completion rates, Study selection and data extraction
thus improving this modifiable risk factor in deconditioned Studies identified during the electronic database search were
patients by exercising during treatment may improve clinical imported in the data management software for systematic
outcomes.26 Although there is a growing body of evidence reviews, Covidence (Veritas Health Innovation, Melbourne,
supporting the role of exercise in cancer care, it remains unclear Australia; available at www.covidence.org). Duplicate titles were
whether exercising during prolonged cancer treatment regimens removed. Abstract and title screening were screened initially,
can reduce hospital length of stay. This study proposed to fill followed by full-­text review and then data extraction, with each
the gap in the literature regarding the effect of exercise during step dual-­screened between three independent authors (100%
frequently prescribed cancer treatments on hospital outcomes, by DM, and 50% each by HW and YR). Authors (DM, AM,
and by specific exercise parameters (type, frequency, and level MD, CTVS, DPS and TL) have prior experience with conducting
of supervision), in adults and children with cancer. The primary systematic reviews and meta-­ analyses. To ensure consistency,
aim of this study examined the effect of exercise interventions on reviewing coauthors (DM, HW and YR) received guidance from

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 Systematic review

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a university librarian with expertise in systematic reviews, and likelihood random effects estimation. Furthermore, statistical
underwent weekly meetings over 12 weeks to discuss progress heterogeneity was assessed by means of an I2 test and was cate-
and challenges. Conflicts were resolved by discussion among these gorised as low (<50%), moderate (51–75%) or high according
three authors, with an external reviewer consulted if consensus to predefined criteria.33 This was calculated to estimate how
could not be achieved (CTVS). Study details extracted included much the total variability in the effect size estimates was due
country, recruitment dates, age, sex, type of cancer diagnosis to heterogeneity among the true effects.34 To further assess
and treatment type (ie, chemotherapy, radiotherapy, HSCT) of heterogeneity, subgroup analyses were performed by the cancer
participants. Data extraction for exercise intervention character- treatment (ie, chemotherapy only, chemotherapy and radiation,
istics included type (eg, aerobic, resistance), dose (eg, sessions, HSCT), with sensitivity analyses conducted by exercise type,
repetitions, intensity), frequency (eg, times per week), setting number of sessions and level of supervision. Additionally, we
(eg, supervised in-­hospital, home-­based), duration (eg, minutes, tested the association between the mean difference effect and
weeks), compliance (ie, number of sessions completed compared each subgroup using meta-­regression. The possible presence of
with prescribed) and what the control group was instructed to publication bias was assessed using Egger’s test.35 All analyses
do. Hospital length of stay data was reported as days spent in were conducted using Stata V.18 (StataCorp, College Station,
hospital and proportion of the study group admitted to hospital. Texas, USA).
Authors from studies with incomplete data on hospital length of
stay outcomes were contacted on up to two occasions.
Protocol deviations
Quality assessment Our final manuscript deviated from the original PROSPERO
The Cochrane Risk of Bias 2 tool (RoB 2) was used to assess registration by focusing only on RCTs, adding adverse events
the risk of bias of the RCTs.30 The RoB 2 evaluates sources of as a secondary outcome, conducting sensitivity analyses inves-
bias from random sequence generation, allocation concealment, tigating the effect of different exercise doses on hospitalisation
blinding of personnel, patients and outcome assessors, incom- outcomes, and searching four rather than six electronic data-
plete outcome data, selective outcome reporting and other bases (details listed in online supplemental table 3).
sources. Each bias category was ranked as ‘low’, ‘high’ or ‘some
concerns. All studies were dual-­assessed for bias between inde-
pendent researchers (100% by JKLL, and 50% each by TL and Patient and public involvement
CTVS), with disagreements resolved by discussion with the lead Patients and/or the public were not involved in the design, or
author (DM). conduct, or reporting of this research, however the author-
The quality of evidence was determined using the Grading ship team will disseminate the findings through their estab-
of Recommendations Assessment, Development and Evaluation lished consumer networks (ie, oncology community and
(GRADE) system,31 categorising the level of evidence as ‘high’, non-­government organisations).
‘moderate’, ‘low’ or ‘very low,’ using the criteria: risk of bias,
inconsistency (ie, unexplained heterogeneity), indirectness (ie,
population, intervention and/or outcome differences), impreci- Equity, diversity, and inclusion statement
sion (ie, wide CIs leading to uncertainty) and other consider- The author group is gender-­ balanced and consists of junior,
ations (eg, publication bias). mid-­career and senior researchers from different disciplines
(including exercise physiology, implementation science, medical
oncology, epidemiology and biostatistics). Although the research
Outcomes was conducted in Australia, some of the research teams are from
The primary outcome of interest was the potential effect of different countries and a range of ethnicities. All the studies
participating in an exercise intervention during cancer treatment reported in this manuscript were conducted in high-­ income
on hospital length of stay, frequency of hospital admissions or countries, with the small number of studies reporting ethnicity
proportion of study group admitted to hospital, compared with having a high Caucasian representation, and thus we acknowl-
a usual-­care control group. Adverse events of the exercise inter- edge the findings may not be generalisable to low-­income and
ventions were reported as a secondary outcome. middle-­income countries and other ethnicities, warranting
addressing in future studies.
Data synthesis and analysis
Descriptive statistics were used to summarise study character-
istics. Tables and figures were also used to present the data. RESULTS
Inter-­rater reliability for all dual-­screened processes was assessed Literature search
by calculating the proportional agreement between assessors. A total number of 4349 studies were retrieved through the initial
Hospital length of stay was reported as a continuous outcome search strategy. After removing 430 duplicates, 3919 abstracts
(days), while rate of hospital admission was reported as a dichot- were initially screened. After screening the titles and abstracts,
omous outcome. In the initial stage of the meta-­analysis, means 118 full-­text articles were read. Following the full-­text review of
and SD were extracted from the included studies where the these publications, 98 studies were excluded based on the inclu-
outcome was continuous. If not reported, we derived means and sion and exclusion criteria. Finally, 20 articles were included in
SD from sample size, median, IQR, minimum and maximum the systematic review,36–55 and 19 articles in the meta-­analyses
values.32 When the outcome was dichotomous, the number of (figure 1).36–42 44–55 One study was not included in the meta-­
events and total number of participants were extracted. Effect analysis because it did not include data about hospital length of
sizes in the form of mean difference or differences in propor- stay despite conducting a between-­group comparison.43 There
tions with their 95% CIs were then calculated for each study, was good inter-­rater agreement in the initial abstract screening
which were presented by treatment type. To handle heteroge- (96% proportional agreement) and 72% agreement at the assess-
neity from study effects were pooled using restricted maximum ment for full text inclusion.

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Figure 1 Flow chart of included studies.

Study characteristics Exercise programme details

Study characteristics are reported in table 1. The systematic The median exercise intervention length was 5.5 weeks
review included data from 2635 participants recruited (1383 (range 2–52). Most interventions included moderate inten-
in exercise interventions and 1252 in control groups), with sity exercise (n=18),36–53 with one study being low inten-
a median sample size across studies of 70 (range: 29–711). sity54 and one not reporting intensity.55 The mean length of
Sixty-­two per cent of participants were women. Eighteen studies sessions was 38 min (SD: 14, range: 10–70) and 4.4 sessions/
were conducted in adults (mean age=52.2±10.9 years)37–40 42–55 week (SD: 1.7, range: 2–7). Interventions were fully super-
and two studies in children (mean age=11.0±3.5 years).36 41 vised (n=11)36 37 39 41 42 48–50 52–54 or partially supervised with
Studies were conducted in Germany (n=7),38 41 42 49 52–54 the USA a home-­ based component (n=7),38 40 44–46 51 55 and unsu-
(n=5),36 43 44 51 55 Canada (n=2),37 40 Sweden (n=1),50 Denmark pervised (n=2).43 47 Of supervised programmes, n=15 were
(n=1),39 France (n=1),47 Scotland (n=1),45 Switzerland (n=1)48 delivered one-­on-­one,36–42 44 49–55 and n=3 were group-­ based
and Netherlands (n=1).46 Studies were conducted in patients sessions.45 46 48 Median compliance with exercise interventions,
with haematological cancers (n=14),36–41 43 44 49 51–55 breast which was reported in 15 studies, was 70.7% (SD: 22.3%, range:
cancer (n=2)45 50 and mixed solid tumours (n=4).42 46–48 Studies 54–94.4%). The average withdrawal rate was 28% and 24% in
were conducted during HSCT (n=12),36 38–41 43 44 51–55 chemo- exercise and control groups, respectively.
therapy (n=3),37 49 50 chemoradiation (n=4)45–48 and across both
chemotherapy and HSCT (n=1).42 The median recruitment rate Additional interventions delivered
was 71% (range 18–99%). There is clear evidence of clinical In addition to delivering the exercise intervention, some inter-
heterogeneity in the included studies as shown by the diversity vention groups also received relaxation (n=3),39 40 43 dietary
in the study populations, both in age and sex. guidance (n=2)48 49 and motivational interviewing (n=1).45

EXERCISE INTERVENTIONS Control groups

Type of exercise interventions While three control groups received usual care only,42 46 48 other
Data regarding the exercise interventions are presented in control groups received other interventions including resources
table 2. Exercise interventions were combined aerobic, resistance (n=5),40 43 45 47 50 physiotherapy (n=4),39 49 53 54 exercise
and stretching (n=6),36–41 aerobic only (n=4),42–44 55 aerobic and education (n=2),39 51 mental relaxation (n=2),36 41 bike access
resistance (n=2),45 46 aerobic, resistance and balance (n=2),47 48 (n=2),40 55 a pedometer (n=2)38 44 and stretching and gymnastics
aerobic versus resistance (n=2),49 50 resistance only (n=1),51 sessions (n=1).52 Additionally, two control groups were offered
aerobic, stretching and activities of daily living (n=1),52 aerobic, the study exercise intervention after the control period.40 45
resistance, stretching and activities of daily living (n=1)53 and
whole body vibration (n=1).54 In summary, aerobic exercise Hospital length of stay and rate of admissions
(n=17/20) and resistance exercise (n=14/20) were the most All 20 included studies described the length of stay (n=17)
commonly used interventions in the included trials. or rate of admission (n=5) in the exercise intervention and

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Table 1 Clinical characteristics of included studies
Total number of
participants (% of
eligible, consented,
Country Date of recruitment Age range, years (mean±SD) and randomised) Female Diagnosis, stage (if known)
Haematopoietic stem cell transplantation
 Potiaumpai USA NR 40–80 (58.8±7.6) 35 (61) 16 (46) AML, ALL, CLL, MDS, MM, other
 (2021) lymphomas
 Pahl Germany Jun 2016 – Oct 2017 32–63 44 (NR)* 14 (32) AML, ALL, CLL, CMML, MDS, MM,
 (2020) Exercise: 50–63 (55), myelofibrosis, SG, severe aplastic
Control: 32–63 (56) anaemia
 Santa Mina Canada Oct 2014 – Oct 2018 >17 30 (15) 15 (50) Leukaemia, lymphoma, MDS,
 (2020) Exercise: 50.4±18.1, MNGIE
Control: 48.4±13.0
 Senn-M
­ alashonak Germany Jan 2011 – Dec 2014 Median (range). 70 (42) 48 (69) Leukaemia, MDS, lymphoma,
 (2019) Exercise: 5–17 (11), neuroblastoma, nephroblastoma,
Control: 6–18 (12) nasopharynx carcinoma, soft
tissue sarcoma
 Wallek USA Jan 2011 – Dec 2014 5–17 (10.9±3.5) 53 (32) 18 (34) Leukaemia, MDS, solid tumour,
 (2018) lymphoma
 Hacker USA May 2013 – Aug 2015 19–73 (53.3±12.2) 67 (37) 26 (39) Haematological cancer
 (2017)
 Jacobsen USA Jan 2011 – Jun 2012 18–76 711 (NR) 306 (43) AML, ALL, CML, CLL, MDS, MPS,
 (2014) Median: MM, PCD, lymphoma
Exercise: 58 (20±76)
Exercise+Stress management: 57
(20±75) Stress management: 57
(18±75)
CON: 55 (19±76)
 Wiskemann Germany May 2007 – Oct 2007 18–71 (48.8) 105 (94) 34 (32) AML, ALL, CML, CLL, MDS,
 (2011) secondary AML, MPS, MM, other
lymphomas, aplastic anaemia
 Baumann Germany 2002–2005 Exercise: 41.41±11.78 47 (NR) 17 (52)† AML, ALL, CML, CLL, MPS, MDS,
 (2011) Control: 42.81±14.04 CMML, MM, PID
 Baumann Germany Mar 2002 – Jul 2004 Exercise: 44.9 ±12.4 Control: 64 (NR)§ 29 (45) AML, ALL, CML, multiple
 (2010) 44.1±14.2 myeloma, NHL/CLL, MDS/MPS,
solid tumour
 Jarden Denmark Apr 2005 – Nov 2007 18–65 (39.1±12.2) 42 (51) 16 (38) AML, ALL, CML, AA, MDS, WM,
 (2009) PNH, myelofibrosis
 DeFor USA Jul 2003 – Aug 2005 18–68 (47) 100 (82) 39 (39) Haematological cancer
 (2007)
Chemotherapy alone
 Mijwel Sweden Mar 2013 – Jul 2016 18–70 240 (28) 240 (100) Breast cancer
 (2020) Aerobic: NR (54.4±10.3) Stage I-­IIIa
Resistance: NR (52.7±10.3)
Control: NR (52.6±10.2)
 Wehrle Germany Jun 2010 – Feb 2013 Aerobic: 47.7 (21.9±63.4) 29 (74) 9 (41)‡ Acute leukaemia
 (2019)
 Alibhai Canada Jun 2011 –Feb 2013 23–80 (57±14.7) 81 (71) 37 (46) AML
 (2015) Mixed cytogenetic risk group
HSCT+chemotherapy
 Dimeo42 Germany NR 18–60 70 (88) 51 (73) Solid tumours
EX: NR (39±10)
CON: NR (40±11)
Chemo- and radiotherapy
 Arrieta47 France Oct 2011 – May 2016 76.7±5.0 301 (67) 180 (60) Breast cancer
Colon cancer
Hepatocellular carcinoma,
Adenocarcinoma, Lymphoma
 May Netherlands 2010–2013 25–75 194 (82) 176 (91) Breast cancer
 (2017) Breast (Exercise: 50±7.9, Control: Colon cancer
49.4±7.6), Stage I-­III
Colorectal (Exercise: 57.4±11.2,
Control: 59.1±8.9)
 Mutrie Scotland Jan 2004 – Jan 2005 29–76 (51.9±9.5) 201 (65) 201 (100) Breast cancer
 (2007) Stage 0-­III
Continued

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Table 1 Continued
Total number of
participants (% of
eligible, consented,
Country Date of recruitment Age range, years (mean±SD) and randomised) Female Diagnosis, stage (if known)
 Uster Switzerland Mar 2012 – Oct 2014 32–81 (63.0) 58 (48) 18 (31) Gastrointestinal cancer
 (2018) Lung cancer
Stage IV
Data presented as range (mean) or number (%). NR denotes not reported.
*Per-­protocol analysis.
†14 patients deceased during hospitalisation, leaving behind 33 survivors.
‡Reasons for prematurely terminating study participation were mental overload (n=3), change in diagnosis (n=2), persistent thrombocytopenia <10/nL (n=1) or death (n=1),
none of which were associated with exercise—leaving behind 22 participants.
§15 (8 of the treatment arm and 7 of the control arm) deceased during hospitalisation for HSCT.
AA, aplastic anaemia; ALL, acute lymphocytic leukaemia; AML, acute myeloid leukaemia; AT-­HIIT, moderate-­intensity aerobic and high-­intensity interval training; CLL, chronic
lymphocytic leukaemia; CML, chronic myeloid leukaemia; CMML, chronic myelomonocytic leukaemia; HSCT, haematopoietic stem cell transplantation; MDS, myelodysplastic
syndrome; MM, multiple myeloma; MNGIE, mitochondrial neurogastrointestinal encephalopathy syndrome; MPS, myeloproliferative syndrome; NHL, non-­Hodgkin's lymphoma;
PCD, primary ciliary dyskinesia; PID, primary immune deficiency; PNH, paroxysmal nocturnal haemoglobinuria; RT-­HIIT, resistance and high-­intensity interval training; SAA, severe
aplastic anaemia; SG, septic granulomatosis; WM, Waldenstrom macroglobulinaemia.

control groups (table 3). Of the 17 studies reporting on length not conducted for this meta-­analysis. There was no evidence of
of stay (days), only one study presented statistically significant statistical heterogeneity, as I2=0.
reductions in hospital length of hospital stay, with Dimeo et al In sensitivity-­
analyses, meta-­ regression on main outcomes
that identifying that participants who cycled for 30 min/day mean difference and exercise type, number of sessions and level
for 4 weeks, averaged 13.6 (2.2) days in hospital versus 15.2 of supervision, removing studies with a control groups which
(3.6) days in the control group (p=0.03).42 In the five studies were offered exercise equipment but no prescribed intervention,
reporting the proportion of patients admitted to hospital in the and separating by adult and child studies, did not explain the
study period,37 45 47 50 51 two reported statistically lower rates variation in either hospital length of stay or admission outcomes
of hospital admission among the exercise groups. Mijwel et (online supplemental file 1).
al found that 2/74 (3%) and 4/72 (6%) of participants, who
received two 60min/week resistance, or aerobic exercise, respec-
tively, plus high-­intensity interval exercise for 16 weeks, were Adverse events from exercise interventions
hospitalised throughout their treatment compared with 8/60 Ten studies reported investigating adverse events. Of these,
(13%) of the control group (p=0.02).37 Mutrie et al found that eight reported no adverse events from the exercise interven-
participants who undertook three sessions/week of moderate tions.37 39–41 45 48 49 53 One study reported no serious adverse
multimodal exercise for 12 weeks were hospitalised at half the events, however documented two exercise sessions that ceased
rate throughout treatment compared with the control group early due to two minor adverse events, including knee pain
(10/99 (10%) vs 20/102 (20%), p=0.04).36 and discomfort.54 One study, which reported no adverse
events from the exercise intervention, had one participant
fall during the baseline 6-­minute walk test, and subsequently
Meta-analysis withdrew from the study.40 Finally, one study reported that
Sixteen studies reporting hospital length of stay were included participants kept a daily log which included self-­reporting of
in the meta-­analysis (522 in exercise interventions and 473 in adverse events, however these findings were not presented in
control groups).36–46 48 49 51–55 For hospital length of stay, there the article.38
was a small effect size for all pooled studies favouring the exer-
cise groups spending 1.40 days less (95% CI: −2.26 to −0.54,
p<0.01) in hospital compared with the control groups (figure 2). Quality assessment
Subanalyses found a small effect that the exercise groups spent Over two-­thirds of included studies had at least one risk of
1.55 days less (95% CI: −2.61 to −0.50) for HSCT compared bias domain that was judged to be high risk (online supple-
with usual care. In other treatment protocols, the exercise groups mental figures 1 and 2). These trials were at high or unclear
spent 0.67 days less (95% CI: −4.24 to 2.91) for chemotherapy) risk for selection bias relating to the randomisation, devia-
and 0.86 days less (95% CI: −2.09 to 0.36) for combined tions from the intended interventions, missing outcome data,
chemotherapy and radiation compared with usual care, however measurement of the outcome or selective reporting. Based
these subanalyses were not statistically significant. Egger’s test on the GRADE rating system, the evidence for the effect of
suggested no evidence of publication bias (p=0.68). The amount exercise on hospital length of stay was low quality, and low
of statistical heterogeneity was low with overall I2=22.86% and quality for rate of admissions (online supplemental table 4).
subgroup I2 not exceeding 24.82%. The quality of evidence was downgraded because of risk of bias
Five studies reporting the rate of hospital admission were due to methodological limitations identified using the RoB 2,
included in the meta-­analysis (446 in exercise interventions and and imprecision, due to the confidence intervals being close
360 in control groups).37 45 47 50 51 There was a small effect size to the no difference line. Due to the variability of bias assess-
in the pooled analysis favouring exercise (figure 3). There was ments, which ranged from low to high across the five domains,
an 8% reduced risk of hospital admission in the exercise group especially for the second domain (ie, bias due to deviations
(difference in proportions: −0.08, 95% CI: −0.13 to −0.03, from intended interventions), the presence of methodological
p<0.01). As only five studies were pooled, Egger’s test was heterogeneity is highly likely.

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Table 2 Exercise intervention characteristics of the included studies
Author Days/week, duration Intensity Exercise Control Co-­interventions Duration Compliance/adherence
Haematopoietic stem cell transplantation
Potiaumpai et al 4 days/week (3×supervised, 5-­6/10 RPE (moderate) Multidirectional walking Physical activity No 1 month Walk: 79
1×unsupervised) for multidirectional drills: counselling
(Duration increased drills and 7-­8/10 RPE ► A weighted eight-­ Given encouragement to
gradually from 5 to 30 min) (high) for walking rung agility ladder be physically active
► Forward, backward, Self-­monitor their daily
sideways, and steps using a pedometer
diagonal walking
Pahl et al Daily, one-­on-­one training Low Whole-­body vibration Conducted mobilisation No 5.5 weeks NR
(20 mins/each) training of the legs of the spine and
standing on the side-­ stretching of the whole
alternating vibration body
plate
Santa Mina et al 3 days/week: 1×supervised Aerobic: 60% hour Resistance bands and Stationary bikes and No 3 months Inpatient phase
facility-b­ ased and reserve exercise diary were exercise placards Aerobic: 50
2×unsupervised home-­ given (in-­door exercise Resistance: 99
based sessions 3 to 5 min aerobic recommendations) were Control: NR
(90–150 min per week) warm-u­ p provided
30 to 45 min resistance
training involved the use
of free weights and/or
resistance bands
10 to 15 min aerobic
exercise: stationary bike,
treadmill, or elliptical
trainer
Aerobic exercise in the
home setting involved
brisk walking
Sessions concluded with
yoga-­based stretching
and relaxation breathing
Senn-­Malashonak 5 days/week Aerobic: Moderate Resistance, endurance, Mental and relaxation No 3 months Exercise: 94
et al (30–60 mins/each) (12-1­ 4/20 RPE) and flexibility training training Control: 68
Resistance: 1–3×7–15
reps of 3–5 exercises
Wallek et al 5 days/week Aerobic: 60– Use of barbells, balls, Mental and relaxation No 2 months Exercise: 94
(40–60 min/each) 80% HRmax, 12-­14/20 rubber bands, steps, and training (3.1±0.6 sessions per
RPE. bicycle ergometer. week)
Resistance: 1–3×8–15 Training intensity
reps for 3–6 exercises was controlled via
self-­reported rating of
perceived exertion
Hacker et al 3 days/week Moderate, 13/20 RPE Progressive resistance During hospitalisation, Education 2.5 weeks 83 for exercise sessions
(1×supervised and 2 x and strength training two visits per week included health 97 for education sessions
unsupervised) using: during which hospital protection,
18 strength training sessions ► Elastic resistance experience was working with
bands discussed. doctors, finances,
► Body weight (be After discharge, 1-­on-­ recommendations
it sit-­ups or wall 1 health education after HSCT
push-­ups) sessions (1 /week, 6
weeks).
Jacobsen et al 3–5 days/week Moderate: 50%– One of four A DVD, alongside brief Pedometer and Duration of 67: self-­guided relaxation.
(20–30 min/each) 75% hour reserve interventions: self-­ discussion with an a relaxation CD inpatient 34: deep breathing
directed exercise, interventionist, were were provided. stay 12: relaxation audiotapes
self-­administered provided. Only general Patients were 4: videos
stress management, advice regarding re-­contacted at
combinatorial exercise exercise and stress 30 and 60 days
and stress management management was post HSCT to
training, or usual care offered (such that review goals,
A pamphlet, a digital physical activity patterns barriers, and offer
video disc (DVD) and a and participants’ own encouragement.
diary were given. stress management
Stress management techniques were
training involved maintained).
targeted-­paced
abdominal breathing,
muscle relaxation, and
coping strategies
Continued

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Table 2 Continued
Author Days/week, duration Intensity Exercise Control Co-­interventions Duration Compliance/adherence
Wiskemann et al In-p­ atient intervention: Moderate-h­ igh Endurance training: Step counters were No 6 weeks Before admission: 88
3–5 x endurance sessions Aerobic: 12-­14/20 RPE 20 to 40 min walking given to record daily During hospitalisation: 83
during hospitalisation for 20–40 mins in the outpatient physical activity. After discharge (for 6–8
2 x resistance sessions per Resistance: 14-­16/20 setting. Cycling and Controls were visited at weeks): 87
week RPE for 2–3 x 8–20 treadmill walking during the same frequency by
(20–40 min/each) repetitions hospitalisation research staff.
Strength training Controls had access to
involved the use of treadmills and stationary
stretch bands and cycles to complete
focuses on the upper themselves (but not
or lower extremities, prescribed)
the whole body, or bed
exercises (inpatient
settings)
Baumann et al Twice a day Exercise: ‘slightly Endurance training was Standard physiotherapy No 7.5 weeks NR
(2011)53 Endurance training strenuous’ or conducted on a cycle Individual active and
(10–20 min/day) ‘strenuous’ (Borg scale) ergometer; if unable passive mobilisation
Activities of daily living Control: low intensity, to complete this for treatment – 10 min
training (ADL-­training) 'not strenuous’ (Borg 10 to 20 min without gymnastic, 5 min
(20 min/day) scale) disruption, then interval stretching, and
training was conducted. massages – performed
ADL-­training was by a physiotherapist
performed during (5 days a week, 20 min
chemotherapy and each)
post-­engraftment and
involved strength,
coordination, stretching,
walking, and stair
climbing exercises.
Baumann et al Activities of daily living ‘Slight strenuous’ to Aerobic endurance 10 min gymnastics, low-­ No 3.5 weeks NR
(2010)52 training (ADL-­training): ‘strenuous’ (Borg Rate training on a bicycle intensity coordination
5 days/week (20 min/each) f Perceived Exertion ergometer combined training, and massages
Aerobic endurance training: scale) with activities of daily Controls underwent
5–7 days/week (10–20 min ADL-­training low-­intensity active and
each) passive mobilisation,
which consists of
gymnastics, massages,
extensions, and
coordination training.
5 days/week (20 min/
each)
Jarden et al Dynamic exercise: Stationary cycling: low A multimodal ‘Modified logbook’ was Psychoeducation four to 6 81 completed all
5 days/week to moderate intensity, intervention given to document the was based on weeks requirements.
(60±10 min/each) 10-1­ 3/20 RPE encompassing mode, frequency, and behavioural Questionnaires at 3
Resistance training:3 days/ Resistance training: exercise, relaxation, duration of exercise and cognitive months:
week low to moderate and psychoeducation during hospitalisation. therapy Exercise: 81
intensity, 10-­13/20 RPE regarding capacity, Physiotherapy was given techniques Control: 62
Relaxation: low functional performance. after HSCT for up to to facilitate Questionnaires at 6
intensity, 6-­9/20 RPE Dynamic exercises 1.5 hours weekly. adjustment to months:
consisted of neck There was no stationary diagnosis and Exercise: 76
movements, shoulder cycling ergometer treatment. The Control: 62
rotations, hip flexion given unless otherwise aim was to foster
and extension, calf requested. personal control
raise, ankle dorsi-­flexion All outcome measures and increase
and plantar-­flexion, in needed to be completed motivation and
addition to abdominal within the same time self-­efficacy.
and back muscle frame as the exercise
exercises. group.
After cycling, stretching
was conducted.
Resistance training was
comprised of ‘free hand
and ankle weights, bicep
curl, shoulder press,
triceps extension, chest
press, flyer, squat, hip
flexion, knee extension,
and leg curl and
extension’
Continued

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Table 2 Continued
Author Days/week, duration Intensity Exercise Control Co-­interventions Duration Compliance/adherence
DeFor et al Twice a day NR During hospitalisation: Controls were not told No 5 months Adherence to physical
(15 min/each) 15 min walk on a to do any exercise and activity for at least five
treadmill twice a day not given a treadmill times/week:
and cycling for<20 mins/ unless otherwise Exercise: 62
day every other day. requested. Control: 38
After discharge,
participants would walk
at a comfortable speed
for>30 min/day
Chemotherapy alone
Mijwel et al 2 days/week Aerobic: 20 mins Interval training, Exercise No 16 weeks Adherence to the exercise
(60 min/each) moderate intensity combined with recommendations were intervention:
13-­15/20 RPE+3×3 endurance or resistance given (American College RT-­HIIT: 68
mins (high-­intensity), training of Sports Medicine AT-­HIIT: 63
RPE=16–18/20 on guidelines) Adherence to intensity:
cycle RT-­HIIT: 83
Resistance: 70–80% AT-­HIIT: 75
1RM, 2–3x 8–12 reps
+ 3x3 mins (high-­
intensity) RPE=16–
18/20 on cycle.
Wehrle et al 3 days/week Aerobic: 60– Endurance group: Low-­intensity Nutritional 2 months Endurance group: 69
(30–45 min/each) 70% HRmax, RPE=12– training on an upright mobilisation and counselling Resistance group: 76
14/20. stationary bicycle stretching were given to was offered by Control: 60
Resistance: 4–6 x Resistance group: avoid psychosocial bias dieticians and
Body weight, bands/ bodyweight exercises physiotherapists
dumbbell machines. to all participants
RPE=12–14/20.
Alibhai et al 4–5 days/week Light-­moderate, Aerobic, resistance, Walking on a regular No 5 months 54
(30–60 min/each) RPE=3–6/10 and flexibility training basis
exercises Any exercise was
Exercise was documented using
documented using weekly tracking sheets
weekly tracking sheets
Haematopoietic stem cell transplantation and chemotherapy
Dimeo et al Daily 50% cardiac reserve Aerobic exercise (cycling Usual care without No 4 weeks 82 (±10%)
(30 min/each) 15×1 min (mean ergometer in the supine changing daily physical
workload=32±5 Watts) position) activity level
Chemotherapy and radiation therapy
Arrieta et al 2 days/week Low to high and Balance and French National No NR Planned phone calls: 81
focused on avoiding proprioception exercises, Nutrition Health 1 year Exercise: 70
pain and exhaustion aerobic training, and Programme (PNNS) follow-­up
stretching exercises booklet was given, 2 year
which recommends follow-­up
30 min of exercise
per day
May et al 5 days/week (2×supervised, Aerobic: either 5 min warming up, Usual care No 18 weeks Breast cancer: 83
3×unsupervised) ‘3× 2 min increasing 50 min strength training, Habitual physical activity Colon cancer: 89
(supervised: 60 min/each, to 2× 7 min’ or below and 5 min cooling down pattern
home-­based: 30 mins each) ‘3× 4 min decreasing
to 1× 7 min’ ventilatory
threshold.
Resistance: 45–75%
1RM
Home exercise at
moderate intensity
Mutrie et al 3 days/week (2×supervised, Moderate intensity, 45 min supervised group Usual care No 12 weeks Breast cancer: 83
1×unsupervised) 50–75% HRmax exercise: Exercise guideline leaflet Colon cancer: 89
14 exercise classes 5 to 10 min warm up entitled ‘exercise after
(45 min each) 20 min walking and cancer diagnosis’
cycling, low-­level
aerobics, or muscle
strengthening exercises.
Relaxation exercises
Uster et al 2 days/week Aerobic: 10 mins Warm-­up, strength and Usual care without Protein-­rich 12 weeks Mean: 67
(60 min each) warm up. balance training changing their daily snacks and Median: 75
24 sessions in total Resistance: 60–80% physical activity level oral nutritional
1RM supplements post-­
session
Data are range (mean) or number (%).
Adherence is defined as the percentage of hospital days of exercise completed under supervision.
AT-­HIIT, moderate-­intensity aerobic and high-­intensity interval training; 1RM, 1-­repetition maximum (ie, maximal weight that a participant can lift for a single repetition); RPE, rating of perceived
exertion; RT-­HIIT, resistance and high-­intensity interval training.

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Table 3 Hospital length of stay and admission rate among patients in exercise and control groups of included studies
Hospital length of stay (days)
Mean (SD)
Exercise group Control group P value
Haematopoietic stem cell transplantation
 Potiaumpai et al 12.9 (4.3) 11.7 (4.0) 0.41
 Pahl et al 38.0 (range: 35–43.5) 41 (range: 37–44) NR
 Santa Mina et al 27.4 (3.8) 28.6 (3.5) 0.81
 Senn-M
­ alashonak et al 39.0 (range: 22–74) 42.0 (range: 26–93) NR
 Wallek et al Intervention group (fit): 36 (range: 22–74) Control group (fit): 39 (range: 27–53) >0.05
Intervention group (unfit): 40.5 (range: 26–57) Control group (unfit): 43.5 (range: 26–93)
 Hacker et al 16.7 (4.2) 18.1 (5.5) NR
 Jacobsen et al NR NR 0.42
 Wiskemann et al 45.0 (range: 24–92) 43.0 (range: 22–120) 0.64
 Baumann et al53 56.1 (20.7) 51.4 (16.4) NR
 Baumann et al52 41 (25) 43 (33) NR
 Jarden et al 34.7 (5.6) 35.0 (6.1) 0.88
 DeFor et al 32 (IQR: 15–42) 35.5 (IQR: 24.5–38.5) 0.37
 Dimeo et al 13.6 (2.2) 15.2 (3.6) .03
Chemotherapy
 Wehrle et al Aerobic: 33 (IQR: 31–41) 37 (IQR: 34–43) 0.50
Resistance: 35 (IQR: 33–52)
 Alibhai et al 36.5* 35.8* 0.76
Chemotherapy and radiotherapy
 May et al Breast cancer: 1.9 (3.1) Breast cancer: 1.6 (2.8) NR
Colon cancer: 2.6 (4.6) Colon cancer: 8.8 (11.8)
 Uster et al 5.9 (10.3) 8.3 (10.3) 0.18
Rate of hospital admission (%)
 Hacker et al 3/33 (9%) readmitted post- intervention 8/34 (23%) readmitted post-­intervention NR
 Mijwel et al RT+HIIT: 2/74 (3%) of the group 8/60 (13%) of the group RT vs control: .02
AT+HIIT: 4/72 (6%) of the group AT vs control: >0.05
 Alibhai et al 3/57 (5.6%) of group 3/24 (12.5%) of the group 0.26
 Arrieta et al 22/121 (18%) at 1-­year follow-­up 20/128 (16%) at 1-­year follow-­up 1 year: >0.05
21/86 (25%) at 2-­year follow-­up 29/100 (29%) at 2-­year follow-­up 2 years: >0.05
 Mutrie et al 10/99 (10%) 20/102 (20%) 0.04
Hospital length of stay data listed as mean (SD) days, unless otherwise indicated as median with range or IQR.
*SD not reported.
AT, aerobic training; HIIT, high-­intensity interval training; NR, not reported; RT, resistance training.

DISCUSSION could deliver significant health system savings through earlier

Our study reviewed and synthesised data from 20 RCTs exam- discharge as well as improving individual patient outcomes.
ining the impact of participating in exercise interventions during Recent calls have been made to make hospital care more effi-
chemotherapy, radiotherapy or stem cell transplant cancer treat- cient and less costly,59 so our findings to potentially prevent
ment regimens on hospital length of stay and rate of admissions. admissions and reduce the burden on hospital bed pressure and
It found that patients who participated in exercise interventions the healthcare system are timely. Our study adds to the litera-
during treatment spent 1.40 days less in hospital and had an 8% ture a potential intervention to combat hospital length of stay,
lower risk of hospital admission than non-­exercising controls. with a recent systematic review, which did not investigate exer-
However, findings should be evaluated with caution due to the cise interventions, unable to identify any interventions to reduce
low quality of evidence using the GRADE rating system. This hospital length of stay.18 Although our study was not a health
systematic review and meta-­analysis are important as it evaluates
economic analysis, future studies should investigate whether the
a potential low-­cost intervention to mitigate a major concern
cost of delivering exercise programmes offsets the money saved
among patients with cancer, this being lengthy and repeated
from preventing patient admissions and reduced hospital length
hospital stays.
Prolonged hospital stays are associated with increased risk of stay. Given a converging international consensus on incor-
of readmission and mortality.56 Our findings of reduced time porating exercise into standard cancer care,20 21 exercise during
spent in hospital and reduced risk for admissions may have treatment may allow patients to optimise their health and reduce
important implications for the healthcare system, as there can be their likelihood of hospital admission. Organisational limita-
a high financial burden imposed on individuals and institutions tions have been identified as the key barrier to implementing
bearing the costs of repeated and prolonged hospitalisation.57 exercise into routine cancer care, using the expertise of a multi-
In-­patient hospital costs have been shown to account for 68% disciplinary team in implementing and/or prescribing exercise,
of all cancer-­related costs in the first year after diagnosis58 and and preparing broader community-­based exercise groups and
are steadily increasing. Embedding exercise into treatment plans settings will likely assist.60 61

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Figure 2 Meta-­analysis of the difference in days spent in hospital between those patients with cancer participating in an exercise intervention
versus control. Negative values favour exercise. HSCT, haematopoietic stem cell transplantation. REML, restricted maximum likelihood.

Given the known psychological, physical and financial burden before lung cancer surgery.63 64 Additionally, there is moderate-­
of repeated admissions and prolonged hospital stays, supportive quality evidence that preoperative exercise halved the amount
care interventions are urgently required to reduce the likelihood of postoperative complications in patients with lung cancer, and
or duration of hospitalisation. Exercise before cancer treatment, improved postoperative QoL in oral and patients with pros-
termed ‘prehabilitation’, has been shown to improve clinical tate cancer.65 Although our study identified a smaller effect size
outcomes including reduced hospital length of stay. Prehabili- regarding length of hospital stay compared with exercise inter-
tation studies, commonly conducted prior to cancer surgery, ventions delivered prior to cancer surgery, the difference identi-
have been shown to reduce hospital length of stay by up to fied in our study applied on a population-­level may still provide
4 days following gastrointestinal cancer surgery62 and 4–8 days a cost-­effective intervention to assist with reducing pressure on

Figure 3 Meta-­analysis of the difference in the proportion of participants with cancer admitted to hospital in exercise and control groups.
Negative values favour exercise. REML, restricted maximum likelihood.

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the healthcare system, while concurrently applying numerous and stem cell transplant cancer treatments on hospital length of
health benefits. Further, reducing unplanned hospital admissions stay and admission rates. Our methods have multiple strengths
has been shown to reduce healthcare costs,66 which can add to including protocol registration in PROSPERO, a comprehen-
the importance of our study findings. Several issues need to be sive database search strategy, dual-­screening of the abstract and
resolved to adapt current models of cancer care to implement full-­text selection, data extraction, risk of bias assessments and
exercise, including developing a trained workforce, overcoming pooling of data using meta-­analysis of RCTs, representing the
barriers such as payments and ensuring exercise is recom- gold standard of evidence generation. However, our findings
mended by the patient’s medical oncologist.67 One example is by should be interpreted with caution. While statistical heteroge-
adapting oncology models of care from other chronic diseases neity was assessed to be low, clinical and methodological hetero-
such as the WHO’s ‘Package of interventions for rehabilitation’ geneity was not, due to variability in the age and sex of study
for cardiopulmonary conditions, which recommends incorpo- populations and quality of study evidence. Our study was not
rating exercise, healthy lifestyle education and stress manage- able to account for any possible missing data from the included
ment to improve function and clinical outcomes,68 a model studies, which may have affected the statistical calculations and
demonstrating reduced risk and duration of hospital readmis- produced biased estimates.77 Many studies had high risk of
sions and mortality.69 bias, mostly due to high drop-­out, low adherence to the exer-
There are likely multiple mechanisms regarding the effect cise interventions and lack of blinding, highlighting the chal-
of different exercise types during cancer treatment on risk of lenges in conducting allied health interventions78 and presenting
admission and hospital length of stay. Exercise can improve potential difficulties for patients to commit to interventions
physical function by adaptations in cardiovascular (particularly requiring additional visits during the treatment period where
aerobic exercise) and skeletal muscle systems (particularly resis- they are susceptible to various adverse events. Only one study
tance exercise).23 Greater physical function has been shown to in our review had a primary outcome assessing the effect of
decrease hospital length of stay, while patients with reduced exercise on hospitalisation admissions,50 thus future studies that
physical function can be referred for risk-­reduction interventions are adequately powered to measure hospital length of stay are
such as exercise to improve their tolerance of treatment and side required to confirm our findings. There may be confounders our
effects.70 Physical therapy programmes focused on mobility study could not include in the analysis that may have affected
have also displayed evidence to reduce hospital length of stay the relationship between exercise during treatment and hospital
and risk of readmissions,71 with potential reduction in falls risk length of stay, including prediagnosis physical activity levels,
a contributing factor. Exercise has also been shown to reduce baseline fitness, demographic characteristics or insurance status.
depressive and anxious symptoms,23 which may be important Future research which includes analyses by age, sex, cancer type
clinically given poor psychological health associated with longer and other details on potential confounders or effect modifiers,
hospital length of stay and higher likelihood of readmissions.72 as well as including other therapies such as immunotherapy and
People with cancer have displayed a 15–30% increased risk of hormone therapies, will be beneficial. Further data on imple-
being admitted to hospital for a falls-­related injury due to their mentation, cost-­effectiveness and cost-­utility of different exer-
symptoms and deconditioning.73 Balance and muscle strength- cise programmes will also be useful.
ening exercises have numerous clinical benefits, particularly in
older patients, to reduce their falls and fracture risk,74 which CONCLUSION
forms one common mechanism of reducing the risk of being Our systematic review and meta-­analysis of RCTs found that
admitted to hospital as identified in our study. When discussing exercising during treatment led to a significant reduction in days
the potential effect of different exercise types, most studies in spent in hospital and rate of hospital admission. While the effect
our review included an aerobic exercise component, so compar- size of this difference was small, there may be important clin-
isons between exercise types were not possible. Additionally, ical relevance to patients wanting to stay out of hospital, which
sensitivity analyses conducted as part of this study did not iden- also may have economic benefits to healthcare systems. The
tify that there was an optimal exercise type, dose or level of heterogeneity of exercise interventions, patient characteristics,
supervision to reduce time or risk of being admitted to hospital. and quality assessment of the included studies suggested that
Given the current exercise-­oncology guidelines recommend a these findings should be interpreted cautiously. While exercise is
combination of aerobic and resistance exercise,20 21 we recom- factored into some multidisciplinary care plans, its inclusion as
mend a combined exercise programme in-­line with the guide- standard practice for most patients who would benefit should be
lines is likely to be beneficial. considered as cancer care pathways evolve.
Exercise during cancer treatment has been shown to be safe.
For instance, in children with cancer, an evaluation of 35 110 Author affiliations
1
exercise sessions found severe adverse events occurred at a rate The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council
of 0.02%.75 Half the studies in our review reported on safety, in NSW, Sydney, New South Wales, Australia
2
Discipline of Exercise and Sport Science, Faculty of Medicine and Health, The
which most reported no adverse events from exercise. As 10% University of Sydney, Sydney, New South Wales, Australia
(2/20) of our included studies offered no exercise supervision, a 3
School of Public Health, Faculty of Medicine and Health, The University of Sydney,
small risk of both adverse events, and under-­reporting of adverse Sydney, New South Wales, Australia
4
events remains. Supervision should be encouraged during treat- Medical Sciences Division, The University of Oxford, Oxford, UK
5
ment to minimise such possibilities, particularly in the early stages Department of Physiotherapy, University of Melbourne, Melbourne, Victoria,
Australia
of habituating participants to a consistent exercise programme. 6
Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria,
Future studies should systematically report exercise-­ related Australia
7
adverse events to improve the evidence of harms assessment, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Sydney, New South
and could incorporate measurable methods to better understand Wales, Australia
8
Office of the Chief Scientist, The George Institute for Global Health, Sydney, New
patient, caregiver and staff experiences and challenges.76 South Wales, Australia
This is the first systematic review and meta-­analysis to inves- 9
Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario,
tigate the effect of exercise during chemotherapy, radiotherapy Canada

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10
School of Medicine & Dentistry, Griffith University, Gold Coast, Queensland, 2014: an incidence-­based approach in terms of trends, determinants and inequality.
Australia BMJ Open 2019;9:e031874.
13 Australian Institute of health and welfare (AIHW). Cancer in Australia 2021; 2021.
Twitter David Mizrahi @davemiz_EP, Tong Li @TongLiUSYD, Christopher T V Swain 14 Roemer M. Cancer-­related hospitalizations for adults, 2017. In: HCUP Statistical Brief
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from The Daffodil Centre, The University of Sydney, a joint venture with Cancer 16 Schneider N, Dreier M, Amelung VE, et al. Hospital stay frequency and duration
Council NSW, for providing internal review and methodological and strategic of patients with advanced cancer diseases - differences between the most
feedback on the manuscript. frequent tumour diagnoses: a secondary data analysis. Eur J Cancer Care (Engl)
Contributors DM was responsible for the conceptualisation and design of the 2007;16:172–7.
study, and is responsible for the overall content as guarantor. DM, HW and YR were 17 Godara A, Siddiqui NS, Munigala S, et al. Length of stay and hospital costs
responsible for the selection of articles and data extraction. JKLL, TL and CTVS were for patients undergoing allogeneic stem-­cell transplantation. JCO Oncol Pract
responsible for further data extraction and risk of bias assessment with justification. 2021;17:e355–68.
DM, JKLL, CTVS and AM were responsible for assessing study methodologies. DM 18 Siddique SM, Tipton K, Leas B, et al. Interventions to reduce hospital length of stay in
and JKLL were responsible for preparing the tables. MD was responsible for the high-­risk populations: a systematic review. JAMA Netw Open 2021;4:e2125846.
meta-­analysis. All authors were responsible for writing and editing of the manuscript. 19 Watson G, Coyne Z, Houlihan E, et al. Exercise oncology: an emerging discipline in the
All authors approved the final manuscript. cancer care continuum. Postgrad Med 2022;134:26–36.
20 Ligibel JA, Bohlke K, May AM, et al. Exercise, diet, and weight management during
Funding The authors have not declared a specific grant for this research from any cancer treatment: ASCO guideline. J Clin Oncol 2022;40:2491–507.
funding agency in the public, commercial or not-­for-­profit sectors. 21 Cormie P, Atkinson M, Bucci L, et al. Clinical oncology society of Australia position
Competing interests None declared. statement on exercise in cancer care. Med J Aust 2018;209:184–7.
22 Toohey K, Chapman M, Rushby A-­M, et al. The effects of physical exercise in the
Patient consent for publication Not applicable. palliative care phase for people with advanced cancer: a systematic review with meta-­
Ethics approval Not applicable. analysis. J Cancer Surviv 2023;17:399–415.
23 Campbell KL, Winters-­Stone KM, Wiskemann J, et al. Exercise guidelines for cancer
Provenance and peer review Not commissioned; externally peer reviewed.
survivors: consensus statement from international multidisciplinary roundtable. Med
Data availability statement Data are available upon reasonable request. Sci Sports Exerc 2019;51:2375–90.
24 Alizadeh AM, Isanejad A, Sadighi S, et al. High-­intensity interval training can modulate
Supplemental material This content has been supplied by the author(s).
the systemic inflammation and Hsp70 in the breast cancer: a randomized control trial.
It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not
J Cancer Res Clin Oncol 2019;145:2583–93.
have been peer-­reviewed. Any opinions or recommendations discussed are
25 Cormie P, Zopf EM, Zhang X, et al. The impact of exercise on cancer mortality,
solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all
recurrence, and treatment-­related adverse effects. Epidemiol Rev 2017;39:71–92.
liability and responsibility arising from any reliance placed on the content.
26 Groen WG, Naaktgeboren WR, van Harten WH, et al. Physical fitness and
Where the content includes any translated material, BMJ does not warrant the
chemotherapy tolerance in patients with early-­stage breast cancer. Med Sci Sports
accuracy and reliability of the translations (including but not limited to local
Exerc 2022;54:537–42.
regulations, clinical guidelines, terminology, drug names and drug dosages), and
27 Higgins JPT, Thomas J, Chandler J, et al. Cochrane Handbook for Systematic Reviews
is not responsible for any error and/or omissions arising from translation and
of Interventions. Chichester (UK): John Wiley & Sons, 23 September 2019.
adaptation or otherwise.
28 Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews
ORCID iDs and meta-­analyses: the PRISMA statement. Ann Intern Med 2009;151:264–9,
David Mizrahi http://orcid.org/0000-0003-1174-2248 29 Schardt C, Adams MB, Owens T, et al. Utilization of the PICO framework to improve
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David P Smith http://orcid.org/0000-0002-1474-3214 assessing risk of bias in randomised trials. BMJ 2011;343:d5928.
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