Open access Protocol

Effect of different types of exercise on

BMJ Open: first published as 10.1136/bmjopen-2019-031374 on 3 November 2019. Downloaded from http://bmjopen.bmj.com/ on July 21, 2024 by guest. Protected by copyright.
health-­related quality of life during and
after cancer treatment: a protocol for a
systematic review and network meta-­
analysis
Esther Ubago-­Guisado,1 Luis Gracia-­Marco,2,3 Iván Cavero-­Redondo,1,4
Vicente Martinez-­Vizcaino,1,5 Blanca Notario-­Pacheco,1
Diana P Pozuelo-­Carrascosa ‍ ‍ ,1 Esther G Adalia,1 Celia Álvarez-­Bueno ‍ ‍ 1,4

To cite: Ubago-­Guisado E, ABSTRACT

Gracia-M ­ arco L, Cavero-­ Strengths and limitations of this study
Introduction Cancer (and survival) is known to affect the
Redondo I, et al. Effect of quality of life. Strategies as physical activity and exercise
different types of exercise ►► This study presents an explicit and replicable meth-
during and after cancer may improve health-­related qualify
on health-­related quality of odology for analysing the effect of different types
of life (HRQOL) outcomes and are, therefore, of clinical and
life during and after cancer of physical exercise on health-­related quality of life
treatment: a protocol for a public health importance. To the best of our knowledge,
during and after cancer treatment, enhancing trans-
systematic review and network comparative evidence of the effect of the different types of
parency of research, reducing publication bias, pre-
meta-­analysis. BMJ Open exercise on improving HRQOL in cancer patients has not
venting selective publication and selective reporting
2019;9:e031374. doi:10.1136/ been synthesised thus far. We aim to conduct a systematic
of research outcomes.
bmjopen-2019-031374 review and network meta-­analysis in order to synthesise
►► The publication of this protocol for a systematic
all available evidence regarding the effect of different
►► Prepublication history and review and network meta-­analysis prevents unnec-
additional material for this types of exercise interventions on HRQOL during and after essary duplication of research, helping researchers
paper are available online. To cancer treatment. to know which criteria for inclusion of trials are
view these files, please visit Methods and analysis MEDLINE (via PubMed), planned to be considered in the systematic review
the journal online (http://​dx.​doi.​ Web of Science, Embase, The Cochrane Library and and network meta-­analysis
org/​10.​1136/​bmjopen-​2019-​ SPORTDiscus will be searched from inception to ►► The assessment of risk of bias of the selected stud-
031374). December 2018 for relevant randomised controlled ies and heterogeneity among studies included, with
trials (RCTs) and non-­RCTs. Studies assessing physical particular reference to sample characteristics, is a
Received 30 April 2019
activity and exercise interventions in cancer patients featured point in this evidence review.
Revised 03 October 2019
Accepted 04 October 2019 (during treatment) and survivors (after treatment) will be ►► Potential limitations of this research could be
selected. Two independent reviewers will identify eligible publication bias, information bias, poor statistical
studies. After quality appraisal and data extraction, we analysis and inadequate reporting of methods and
will conduct meta-­analyses for outcomes of interest, findings within the included studies.
including data from mental and physical dimensions of ►► This work will follow the existing guidelines includ-
cancer-­specific and/or generic HRQOL questionnaires. ed in the Preferred Reporting Items for Systematic
Risk of bias assessments will be completed using the Review and Meta-­ Analysis and the Cochrane
Quality Assessment Tool for Quantitative Studies. Study Collaboration Handbook, and it will take into account
heterogeneity will be measured by the I2 statistic. Bayesian potential risks of bias for each study.
(and traditional approach) network meta-­analysis will be
performed when possible to determine the comparative
effect of the different physical activity or exercise
interventions. Introduction
© Author(s) (or their Ethics and dissemination This systematic review and Cancer is a major cause of burden of disease
employer(s)) 2019. Re-­use
network meta-­analysis will synthesise evidence on the worldwide and is responsible for one out of
permitted under CC BY-­NC. No
commercial re-­use. See rights effect of different types of exercise interventions on three deaths globally.1 2 However, as a conse-
and permissions. Published by HRQOL during and after cancer treatment. The results will quence of early diagnosis and timely treat-
BMJ. be disseminated by publication in a peer-­reviewed journal ment strategies, survival rates are improving
For numbered affiliations see and through scientific conferences and symposia. Ethical in such a way that cancer is now recognised as
end of article. approval will not be required because the data used for a chronic disease. Although improvements in
this work will be exclusively extracted from published the effectiveness of treatment options could
Correspondence to studies.
Iván Cavero-­Redondo; improve survival,3 they also have a nega-
PROSPERO registration number CRD42019125028.
​Ivan.​Cavero@u​ clm.​es tive impact on physical and psychological

Ubago-­Guisado E, et al. BMJ Open 2019;9:e031374. doi:10.1136/bmjopen-2019-031374 1

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functions such as depression, anxiety, fatigue, pain, sleep P) statement19 and the Cochrane
Protocols (PRISMA-­
quality and stress, all of which can affect the quality of life Collaboration Handbook.20
of cancer patients.4
Health-­related qualify of life (HRQOL) is a multidi- Inclusion/exclusion criteria for study selection
mensional construct reflecting patients’ perceptions Type of studies
regarding the effect of disease and its treatment on their Because of the likely scarcity of studies, in addition to the
physical, psychological and social functioning, and well-­ barriers for randomisation of some interventions in cancer
being.5 Importantly, growing evidence confirms that patients, the eligible studies will include randomised
cancer survivors, especially younger patients, continue controlled trials, cluster randomised trials, cross-­ over
experiencing the detrimental effects of the disease not trials, non-­ randomised experimental studies and two-­
only during the early years after treatment, but also in arm prepost studies written in English or Spanish. For
the long term.6 Thus, since cancer must be considered the cluster randomised trials, only the studies including
a chronic disease with a negative impact on the physical, the number of participants as unit of analysis will be
social and emotional life of cancer survivors,7 strategies to included. For the cross-­over trials, since the wash out
improve HRQOL outcomes during and after cancer are period could represent an additional source of variability
of clinical and public health importance. we will consider the outcomes of the first period. Only
Physical activity and exercise interventions are peer-­reviewed publications will be included.
powerful tools associated with numerous benefits in
terms of the HRQOL of cancer patients8–13 and survi- Type of participants
vors,9 10 14 15 including improvement in cardiorespiratory Studies assessing physical activity and exercise interven-
and muscular fitness, reduction in fatigue and improve- tions in cancer patients (during treatment) and survivors
ment in body composition and well-­being (ie, depres- (after treatment) will be selected, regardless of the age of
sion, anxiety, sleep quality and quality of life). As such, the participants or cancer site. Cancer patients (during
cancer patients and survivors have been encouraged to treatment) will refer to those that received surgery and/
undertake regular exercise.16 17 However, the benefits that or undergone chemotherapy, radiotherapy or immuno-
different types of exercise have on HRQOL are yet to be therapy as an initial cancer treatment or as a treatment for
extensively studied. metastasis or cancer recurrence. Cancer survivors (after
There is a recent systematic review and network meta-­ treatment) will refer to those not receiving chemotherapy,
analysis by Hilfiker et al18 that evaluated different types of radiotherapy or immunotherapy. Studies including both
exercise and/or other non-­pharmaceutical interventions types of patients will be classified as mixed. When more
on cancer-­related fatigue in any type of cancer during or than one study provides data from the same sample, we
after treatment. They found strong evidence that relax- will only consider the one presenting the most detailed
ation, yoga or cognitive–behavioural therapy, combined results or providing the longest follow-­up data. However,
with physical activity or resistance or aerobic training, data regarding sample characteristics could be extracted
reduces cancer-­ related fatigue substantially more than from multiple reports to obtain the most complete
usual care.18 information.
To the best of our knowledge, comparative evidence of
the effect of the different types of exercise on improving Type of interventions
HRQOL in cancer patients has not been synthesised Eligible studies will report any type of physical exercise
thus far. To achieve this, a network meta-­analysis will be (aerobic, resistance, anaerobic, high-­ interval training,
performed. Briefly, network meta-­analysis is a relatively balance, stretching, alternatives (Pilates, yoga, Tai Chi)
recent technique which extends the principles of meta-­ or a combination (eg, aerobic + resistance)). Physical
analysis to the evaluation of multiple treatments simul- exercise will be understood as repeated bouts over time
taneously in a single analysis by combining direct and involving more than one session/week with a duration
indirect evidence. Therefore, we aim to conduct a system- of at least 4 weeks. However, studies combining phys-
atic review and network meta-­analysis in order to synthe- ical activity and/or exercise with other health-­ related
sise all available evidence regarding the effect of different interventions, such as nutritional interventions, will
types of exercise interventions on HRQOL during and be excluded when data cannot be separately extracted.
after cancer treatment. Other intervention-­related characteristics such as inten-
sity or supervision will be retrieved from each included
study.

Methods and analysis Type of outcome measurements

This protocol has been registered within the PROSPERO Overall HRQOL and specific HRQOL domains (eg,
database for systematic reviews and meta-­analyses (regis- mental and physical domains) from cancer-­specific and/
tration number: CRD42019125028). The protocol has or generic HRQOL questionnaires will be selected for the
been designed and reported following the Preferred meta-­analysis. If the data are available and reliable scales
Reporting Items for Systematic Review and Meta-­Analysis were used, the studies will be combined in a meta-­analysis.

2 Ubago-­Guisado E, et al. BMJ Open 2019;9:e031374. doi:10.1136/bmjopen-2019-031374

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Table 1 Search strategy
cancer AND exercise AND well-­being
OR tumour OR OR depression
OR tumor “physical activity” OR anxiety
OR oncology OR aerobic OR fatigue
OR chemotherapy OR resistance OR
OR radiotherapy OR anaerobic “sleep quality”
OR muscular OR
OR strength “quality of life”
OR cardiovascular
OR flexibility
OR balance

Search strategy type and stage of treatment), (6) intervention characteris-

The literature search will be conducted in the following tics (type of exercise, length, frequency) and (7) outcome
electronic databases from inception to December 2018: measures (baseline and/or follow-­up values).
MEDLINE (via PubMed), Web of Science, Embase, The
Cochrane Library, SPORTDiscus and CINAHL. Searches Assessment of risk of bias
for unpublished studies will be conducted at OPEN The methodological quality of the RCTs will be assessed
GRAY, ProQuest dissertations & Thesis Global, Theseo, using the Cochrane Collaboration’s tool for assessing risk
Networked digital library of theses and dissertations and of bias (RoB2).21 This tool includes five domains: (1) bias
Google Scholar. The search strategy will include the arising from the randomisation process, (2) bias due to
following text free terms (table 1): (cancer OR tumour deviations from intended interventions, (3) bias due to
OR tumor OR oncology OR chemotherapy OR radio- missing outcome data, (4) bias in measurement of the
therapy) AND (exercise OR “physical activity” OR aerobic outcome and (5) bias in selection of the reported results
OR resistance OR anaerobic OR muscular OR strength (online supplementary file 1). To assess the risk of bias in
OR cardiovascular OR flexibility OR balance) AND (well-­ non-­RCTs, the Quality Assessment Tool for Quantitative
being OR depression OR anxiety OR fatigue OR pain Studies will be used.22 This tool evaluates seven domains:
OR stress OR “sleep quality” OR distress OR HRQOL (1) selection bias, (2) study design, (3) confounders, (4)
OR QOL OR “physical functioning” OR “mental func- blinding, (5) data collection methods, (6) withdrawals
tioning” OR “quality of life”). In addition, we will explore and (7) dropouts. For both quality assessment tools,
the reference lists of included articles and retrieve those each domain will be assessed as ‘strong’, ‘moderate’ or
studies that potentially meet the inclusion criteria. ‘weak’, and studies will be classified as low risk of bias
There will be no limitations on the date of publication (with no weak ratings), moderate risk of bias (with one
or on the location of the study. A librarian was consulted weak rating) or high risk of bias (with two or more weak
to draft the search strategy. The literature search will be
independently conducted by two reviewers, and disagree-
ments will be solved by consensus or involving a third
researcher.

Selection of studies and data extraction

Two independent reviewers will identify eligible studies by
screen titles and abstracts, after removing duplicate works
using Endnote software (Thomson Reuters). Reviewers
will then examine the full texts and those that do not
meet the selection criteria will be excluded, verifying the
reasons for exclusion. Inconsistencies or disagreements
will be solved by consensus or involving a third researcher.
The process of identifying, screening and including or
excluding studies will be shown using the PRISMA flow
chart (figure 1).19
The following data will be extracted from the orig-
inal reports by the reviewers: (1) first author and year
of publication, (2) country of the study where data were
collected, (3) length of follow-­up, (4) sample character- Figure 1 Preferred Reporting Items for Systematic Reviews
istics (age, sample size, body mass index, stature, weight, and Meta-­Analyses flow diagram of identification, screening,
type of population) (5) cancer characteristics (cancer eligibility and inclusion of studies.

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ratings; online supplementary file 2). The agreement rate

(hours per
Volume of
between reviewers will be reported by calculating kappa

exercise
statistics. Any inconsistencies will be resolved by the third

week)
researcher.

Grading the quality of evidence

Duration

exercise
(weeks)
The Grading of Recommendations, Assessment, Devel-

Intervention
opment and Evaluation tool will be used to assess the

of
quality of the evidence and make recommendations.23
Each outcome could obtain a high, moderate, low or

Type
very low evidence value, depending on the study design,
risk of bias, inconsistency, indirect evidence, impreci-

Follow-­up
sion and publication bias. By default, RCTs will receive
an initial grade of high and will be downgraded based

values
on the following prespecified criteria: risk of bias (weight
of trials showing risk of bias by the RoB2 tool), inconsis-
tency (substantial unexplained inter-­study heterogeneity,

Baseline
I2>50% and p<0.10), indirectness (presence of factors that

values
limit the generalisability of the results), imprecision (the
95% CIs for effect estimates are wide or cross a minimally

Outcome
important difference for benefit or harm) and publica-

Method
tion bias (significant evidence of small-­study effects).

Statistical analysis

Weight
The reviewers will design qualitative ad hoc tables to
summarise the main characteristics of the selected

(kg)
studies (table 2), describing the types of direct and indi-
rect comparisons. The feasibility of doing a meta-­analysis

Stature
will be assessed after data extraction is completed. If a

(cm)
meta-­analysis is not feasible, a narrative synthesis will be
done. If a meta-­analysis is possible, the random effects
Cancer-­type/time
models based on the DerSimonian-­Laird method will be
Characteristics of studies included in the meta-­synthesis of evidence

used to perform a standard meta-­analysis for each direct

Population characteristics at baseline

comparison between two interventions.24 Study hetero-

geneity will be measured by the I2 statistic and evaluated
period

according to the following criteria: no relevant heteroge-

neity (0%–40%), moderate heterogeneity (30%–60%),
substantial heterogeneity (50%–90%) and considerable
heterogeneity (75%–100%).25 The corresponding p
Sample

male))
(n (%

values will also be considered.

size

To compare the effect of the different types of physical

activity or exercise interventions, a pairwise meta-­analysis
(mean±SD))

for direct and indirect comparisons between interventions

and control/non-­intervention will be carried out. Addi-
(years

tionally, the effects of each intervention will be combined

Age

using Bayesian methods of the Markov-­Monte Carlo chain

using STATA V.15 software. The model developed by Dias
Design

et al26 for the UK National Institute for Health and Care

Excellence Decision Support Unit will be used.
As the indirect comparisons are not protected by
Study characteristics

randomisation and maybe confounded by differences

Country

between the studies, we will check that all the participants

in the studies included in the network meta-­analysis have
the same baseline characteristics (on average) that might
First author
and year of
publication

modify the treatment effect.27

Table 2

A graphic representation of the network will be used to

assess the strength of the evidence, which will show the
number of articles from which the information presented

4 Ubago-­Guisado E, et al. BMJ Open 2019;9:e031374. doi:10.1136/bmjopen-2019-031374

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comes from (treatment nodes), the comparisons that muscular fitness.8 Likewise, a systematic review of 16 RCTs
have direct comparisons and those that present indirect concluded that the practice of aerobic and/or resistance
or mixed comparisons and the number of patients with exercise during therapy (chemotherapy or radiotherapy)
different comparisons, in such a way that confidence in improved muscular strength.31 Another meta-­ analysis
the results will be increased.28 including 25 RCTs demonstrated the beneficial effects
The loop-­ specific approach will be used to evaluate of aerobic, strength and flexibility exercises during treat-
the presence of inconsistency in network meta-­analysis ment in reducing the levels of cancer-­related fatigue.9
models locally.29 Difference (inconsistency factor) with Similarly, two meta-­ analyses of 6 and 9 RCTs, respec-
95% CI between direct and indirect estimations for a tively, found that patients enrolled in aerobic exercise
specific comparison will be calculated to assess the pres- programme during cancer treatment had better sleep
ence of inconsistency in each loop. Inconsistency will quality12 and depression outcomes,10 although the latter
be defined as disagreement between direct and indirect also included a strength training component.
evidence with a 95% CI excluding 0. Post-­treatment exercise has also been associated with
To rank the physical activity and/or exercise inter- benefits to physical fitness, fatigue, mental health and
ventions, the probability of each intervention being the well-­being. Thus, cancer survivors practicing aerobic and
most effective will be presented graphically by ranko- resistance exercise improved cardiorespiratory (evidence
grams. In addition, the surface under the cumulative from seven RCTs) and muscular (evidence from three
ranking (SUCRA) will be calculated for each interven- RCTs) fitness.14 In addition, exercise programme
tion. SUCRA represents an inversely scaled average rank including aerobic, strength and flexibility training have
of the intervention, with a numerical value between 0 and shown benefits towards levels of fatigue (15 RCTs),9
1, the highest value meaning that the intervention always quality of life (11 RCTs),15 anxiety (4 RCTs)15 and depres-
ranks first and the lowest value that it ranks last. The best sion (9 RCTs).10 Finally, evidence from a meta-­analysis
intervention would obtain a value close to 1 and the worst showed improvements in body weight (16 RCTs) and
intervention a value close to 0.30 body fat (10 RCTs) following aerobic and resistance exer-
cise programme.14
Subgroup analyses
In our opinion, the scientific literature lacks a meta-­
Subgroup analyses will be performed based on the type
synthesis of evidence comparing the benefits of different
of participants, type of cancer, type of exercise performed
exercise interventions on HRQOL during and after
and duration of the intervention, because these may be
cancer treatment. A recent systematic review that included
major factors causing heterogeneity.
a network meta-­analysis assessed the effects of different
Sensitivity analysis types of exercise and other non-­pharmaceutical interven-
Sensitivity analyses will be performed by excluding tions on cancer-­related fatigue during and after cancer
the included studies from the analysis one by one and treatment.18 Although cancer-­related fatigue is one of
comparing the results. the most common and distressing symptoms of cancer,18
it is only one of the many components that define the
Patient and public involvement multidimensional concept of HRQOL.5 Recent works
Cancer patient organisations will be involved in both the from Buffart et al32 and Sweegers et al4 evaluated the
discussion of the study results and the dissemination of effect of exercise on quality of life and physical function
the findings among stakeholders. in cancer patients. Our systematic review and network
meta-­analysis will synthesise all the available evidence on
Ethics and dissemination the effects that different types of exercise have on the
The resulting findings of this systematic review and different domains (including both physical and mental
network meta-­analysis could help us develop high-­quality domains) of HRQOL during and after cancer treatment,
recommendations about the type of physical activity and/ using, apart from the traditional meta-­analysis method-
or exercise during and after cancer treatment in order to ology, a comprehensive network meta-­analysis approach
improve the HRQOL. Findings will be disseminated to that allow us to provide both direct and indirect inter-
academic audiences through peer-­reviewed publications, vention’s comparisons.
as well as to clinical audiences, patients’ associations and Potential limitations of this research could be publica-
policy-­makers through conferences and symposia. tion bias, information bias, poor statistical analysis and
inadequate reporting of methods and findings within
the included studies.33 In addition, it is likely that we
Discussion find studies in which the treatment lasted longer than
The health benefits of an active lifestyle during and after the exercise interventions performed, and therefore, we
cancer treatment in the adult population have been might not be able to firmly conclude about the optimal
described in the scientific literature. During cancer exercise dose/duration. This work will follow the existing
treatment, a systematic review of 14 RCTs in patients guidelines included in the PRISMA19 and the Cochrane
undergoing chemotherapy reported a positive effect of Collaboration Handbook.20 In addition, it will take into
resistance and aerobic training in cardiorespiratory and account potential risks of bias for each study.

Ubago-­Guisado E, et al. BMJ Open 2019;9:e031374. doi:10.1136/bmjopen-2019-031374 5

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BMJ Open: first published as 10.1136/bmjopen-2019-031374 on 3 November 2019. Downloaded from http://bmjopen.bmj.com/ on July 21, 2024 by guest. Protected by copyright.
Given the importance of health outcomes in terms of 4 Sweegers MG, Altenburg TM, Chinapaw MJ, et al. Which exercise
prescriptions improve quality of life and physical function in patients
a good quality of life in cancer patients and survivors, a with cancer during and following treatment? A systematic review
more detailed and comprehensive review on the effects of and meta-­analysis of randomised controlled trials. Br J Sports Med
different types of exercise on health parameters in cancer 2018;52:505–13.
5 U.S. Food and Drug Administration. Guidance for industry: patient-­
survivors is necessary. This protocol provides a clear and reported outcome measures: use in medical product development to
structured procedure for maximising the extraction of support labeling claims: draft guidance. Health Qual Life Outcomes
2006;4:79.
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tion. The findings of this systematic review and network metabolic consequences of cancer treatment: a systematic review.
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7 Mishra SI, Scherer RW, Snyder C, et al. Are exercise programs
tioners, researchers and policy-­ makers since they will effective for improving health-­related quality of life among cancer
provide evidence that will assist in the development of survivors? A systematic review and meta-­analysis. Oncol Nurs Forum
2014;41:E326–42.
effective exercise and/or physical activity programme in 8 Van Moll CCA, Schep G, Vreugdenhil A, et al. The effect of
these populations. training during treatment with chemotherapy on muscle strength
and endurance capacity: a systematic review. Acta Oncol
2016;55:539–46.
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1
Universidad de Castilla-­La Mancha, Health and Social Research Center, Cuenca, Care Group. Exercise for the management of cancer-­related fatigue
Spain in adults. Cochrane Database Syst Rev 2012;339:CD006145.
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Group, Sport and Health University Research Institute (iMUDS), Department of depressive symptoms in cancer survivors: a systematic review and
Physical and Sports Education, Faculty of Sport Sciences, University of Granada, meta-­analysis. Cancer Epidemiol Biomarkers Prev 2012;21:3–19.
11 Mishra SI, Scherer RW, Snyder C, et al. Exercise interventions on
Granada, Spain health-­related quality of life for people with cancer during active
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Growth, Exercise, Nutrition and Development Research Group, Universidad de treatment. Cochrane Database Syst Rev 2012:CD008465.
Zaragoza, Zaragoza, Spain 12 Chiu H-­Y, Huang H-­C, Chen P-­Y, et al. Walking improves sleep in
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Universidad Politecnica y artística del Paraguay, Asunción, Paraguay individuals with cancer: a meta-­analysis of randomized, controlled
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Universidad Autónoma de Chile, Facultad de Ciencias de la Salud, Talca, Chile trials. Oncol Nurs Forum 2015;42:E54–62.
13 Rief H, Petersen LC, Omlor G, et al. The effect of resistance training
during radiotherapy on spinal bone metastases in cancer patients - a
Contributors EU-­G, LG-­M, IC-­R and CA-­B conceived and designed the protocol. randomized trial. Radiother Oncol 2014;112:133–9.
BN-­P, DPP-­C and EGA participated in the development of the search strategy. BN-­P, 14 Fong DYT, Ho JWC, Hui BPH, et al. Physical activity for cancer
DPP-­C and EGA planned the data extraction and statistical analysis. EU-­G, VM-­V, survivors: meta-­analysis of randomised controlled trials. BMJ
IC-­R and CA-­B tested the feasibility of the study. EU-­G drafted the manuscript. 2012;344:e70.
VM-­V, LG-­M, IC-­R and CA-­B revised the manuscript. All authors have approved and 15 Mishra SI, Scherer RW, Geigle PM, et al. Exercise interventions on
contributed to the final written manuscript. health-­related quality of life for cancer survivors. Cochrane Database
Syst Rev 2012:CD007566.
Funding This work was supported by the Consejería de Educación, Cultura 16 Schmitz KH, Courneya KS, Matthews C, et al. American College
y Deportes-­Junta de Comunidades de Castilla-­La Mancha and FEDER funds of Sports Medicine roundtable on exercise guidelines for cancer
(SBPLY/17/180501/000533). LG-­M is supported by a Fellowship from "La Caixa" survivors. Med Sci Sports Exerc 2010;42:1409–26.
Foundation (ID 100010434). The fellowship code is LCF/BQ/PR19/11700007. 17 Demark-­Wahnefried W, Peterson B, McBride C, et al. Current
health behaviors and readiness to pursue life-­style changes among
Competing interests None declared. men and women diagnosed with early stage prostate and breast
carcinomas. Cancer 2000;88:674–84.
Patient consent for publication Not required. 18 Hilfiker R, Meichtry A, Eicher M, et al. Exercise and other non-­
Ethics approval Ethical approval and informed consent of patients will not be pharmaceutical interventions for cancer-­related fatigue in patients
required because the data used for this work will be exclusively extracted from during or after cancer treatment: a systematic review incorporating
published studies. All the included trials will comply with the current ethical an indirect-­comparisons meta-­analysis. Br J Sports Med
2018;52:651–8.
standards and the Declaration of Helsinki.
19 Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for
Provenance and peer review Not commissioned; externally peer reviewed. systematic review and meta-­analysis protocols (PRISMA-­P) 2015
statement. Syst Rev 2015;4:1.
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properly cited, appropriate credit is given, any changes made indicated, and the use assessing risk of bias in randomized trials. Cochrane Database Syst
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