Table 3

Characteristics of included reviews

ReviewAims of reviewPrimary studies (n)ParticipantsDefinition of ‘survivor’SettingIntervention, duration and frequencyOutcome—QoL measuresNarrative findings
Buffart et al 11 Systematic review of RCTs and meta-analysis of the effects of yoga in cancer patients and survivors16 publications/13 RCTs744 patients with breast cancer and 39 patients with lymphoma during and after treatment
Mean age range: 44–63 years
Patients during and after treatmentFace to face, with supplementary booklets and audiotapes of exercises for home practiceAll included a yoga programme led by experienced yoga instructors with physical poses (asanas), breathing techniques, (pranayama), and relaxation or meditation (savasana or dhanya)
Programme duration: 6 weeks to 6 months
FACT-G, SF-36, EORTC QLQ-C30, FLICYoga has strong beneficial effects on distress, anxiety and depression, moderate effects on fatigue, general HRQoL, emotional function and social function, small effects on functional well-being, and no significant effects on physical function and sleep disturbances.
Bourke et al 28 To evaluate the evidence from RCTs of supportive interventions designed to improve prostate cancer-specific QoL20 RCTs2654 prostate cancer survivorsPatients during and after treatmentGroup or face to face, online or with supplementary audiotapesLifestyle interventions including exercise interventions, diet interventions or a combination of exercise and diet
Multidisciplinary group education or online education and support
Enhanced standard care interventions and cognitive behavioural interventions
Varied durations and follow-up frequencies
FACT-P, QLQ-PR25, EPIC, EPIC-26, UCLA-PCI, PCa-QoLSupervised and individually tailored patient-centred interventions such as lifestyle programmes are beneficial.
Cramer et al 23 To systematically assess and meta-analyse the evidence for the effects of yoga on HRQoL and psychological health in patients with breast cancer and survivors12 RCTs were included in the qualitative synthesis and 10 of them were included in the meta-analysis.742 patients with breast cancer during or after treatment
Mean age range: 44–63 years
Those who had completed active treatment before the onset of the studyFace to face, with supplementary audio and video tools or telephone callsYoga interventions including Iyengar yoga, Yoga of Awareness, Viniyoga, restorative yoga, yoga based on Patanjali’s yoga tradition, Yoga in Daily Life, integrated yoga and hatha yoga
Duration: 1 week to 6 months
Frequency varied from daily sessions to weekly.
FACT-G, FACT-B, FACIT-Sp, SF-36, SF-12, FLIC, EORTC QLQ-C30There is moderate evidence for the short-term effect of yoga on global HRQoL. However these short-term effects could not be clearly distinguished from bias.
Culos-Reed et al 14 To determine the clinical significance of patient-reported outcomes from yoga interventions conducted with cancer survivors13 studies/7 RCTs474 patients with mixed cancer
The majority were patients with breast cancer during and after treatment.
RCTs: sample size in the treatment group at time 2 ranged from 13 to 45 patients.
Mean age range: 46–60 years
Patients both on and off treatmentFace to faceYoga styles included hatha, integral, Iyengar, Tibetan, Viniyoga and Vivekananda.
Duration: 6–26 weeks
Frequency varied from five times per week to weekly and classes were 60–90 min.
SF-36, EORTC QLQ-C30, FACT-B, FACT-G, SF-12, NHPYoga for cancer survivors results in clinically significant improvements in overall HRQoL, as well as in its mental and emotional domains.
Duijts et al 9 Evaluate the effect of behavioural techniques and physical exercise on psychosocial functioning and HRQoL in patients with breast cancer and survivors56 RCTs>7000 patients with breast cancer, including non-metastatic and metastatic patients during and after treatment
Participants’ ages were not specified.
Patients during and after treatmentFace to face, online or by telephone, individually or at group levelBehavioural techniques included psychoeducation, problem solving, stress management, CBT, relaxation techniques, social and emotional support.
Physical interventions included yoga, self-management exercise protocol, aerobic or resistance exercise training and dance movement.
Intervention duration varied from 1 to 56 weeks of 3–56 sessions.
SIP, CARES, ABS, EORTC QLQ-C30, FACT-B, FACT-G, FACT-F, FACT-An, FLIC, SF-12, SF-36, QoL-BC, GHQ, SDS, IFS-CA, VASThere is no significant effect of behavioural techniques on HRQoL.
Physical exercise produced statistically significant but moderate effects on HRQoL.
Ferrer et al 19 To examine the efficacy of exercise interventions in improving quality of life in cancer survivors, as well as features that may moderate such effects78 studies/43 RCTs3629 participants: 54% breast cancer, 8% prostate cancer, 2% colorectal cancer, 1% each featured endometrial, head–neck, lymphoma and ovarian cancer survivors, and 32% included mixed diagnosis
2432 patients participated in the RCTs.
Mean age was 55 years.
Survivor was defined as post diagnosis.Supervised or unsupervisedInterventions were designed to affect exercise behaviour by comparing low versus high exercise intensity.
36% used trained intervention leaders; 56% featured supervised exercise sessions.
The mean level of targeted aerobic METs was 4.2 (SD=2.2), and the mean level of targeted resistance METs was 2.5 (SD=2.2).
Duration: 8–26 weeks
The mean length of intervention session was 51.1 min and the mean number of sessions per intervention was 22.8.
EORTC QLQ-30, SF-36, FACTIT, Quality of Life Index, FACT-G, FACT-An, FACT-B, FACT H&N, FACT-P, FLIC, CARES-SF, Rotterdam QoL, WHOQOL-BREFThere was a positive effect of physical interventions on QoL, sustained for delayed follow-up assessment.
Efficacy increased as the length of intervention decreased, and if exercise was supervised.
Targeted aerobic intensity significantly predicted QoL improvements as a quadratic trend.
Targeted aerobic METs predicted intervention efficacy.
Number of sessions, targeted resistance METs, training of facilitators and inclusion of flexibility content were not significantly related to QoL outcomes.
Fong et al 10 To systematically evaluate the effects of physical activity in adult patients after completion of main treatment related to cancer34 RCTs3769 participants; 65% included breast cancer only, 9% colorectal cancer only, 3% endometrial cancer only and 27% mixed diagnosis.
Mean age range: 39–74 years
Patients who have completed their main cancer treatment but might be undergoing hormonal treatmentFace to faceExercise interventions included aerobic exercise, resistance or strength training.
Duration: 3–60 weeks
Frequency ranged from daily to once a week.
FACT-G, FACT-B, FACT-C, EORTC, SF-36Physical activity was shown to be associated with clinically important positive effects on quality of life. Aerobic plus resistance training was significantly more effective than aerobic training alone on general QoL.
Fors et al 24 To determine the effectiveness of psychoeducation, CBT and social support interventions used in the rehabilitation of patients with breast cancer18 RCTs3272 patients with breast cancer, during and post treatment
Age range not specified
Patients who have finished surgery and adjuvant treatmentOnline, face to face or by telephone or by using print material, individually or in a groupPsychoeducation, CBT and social and emotional support
Duration ranged from 2 weeks to 6 months.
FACT-B, FACT-G, EORTC-QLQ-C30, QoL-BC, QLI, EuroQoL-5D, QoQ-C33 GlobalPsychoeducation showed inconsistent results during and after primary treatment.
CBT after primary treatment (6–12 weeks) led to improved QoL. CBT during primary treatment had inconsistent results.
Galvão and Newton13 To present an overview of exercise interventions in patients with cancer during and after treatment and evaluate dose-training response considering type, frequency, volume and intensity of training along with physiological outcomes26 studies/9 RCTs1186 patients with mixed cancer during and post treatment
458 patients participated in the RCTs.
Age range: 14–65 years
Patients during and after treatmentFace to faceExercise interventions included a cardiovascular exercise programme and mixed training (cardio, resistance and flexibility exercises). Intensity level when provided was described as between 60% and 80% maximum heart rate.
Programme duration was 4–28 weeks. Frequency ranged from twice a week to five times per week.
Modified Rotterdam QoL SurveyContemporary resistance training provides anabolic effects that counteract side effects of cancer treatments to improve quality of life.
Gerritsen and Vincent20 To evaluate the effectiveness of exercise in improving QoL in patients with cancer, during and after treatment16 RCTs1845 patients with mixed, breast, lymphoma, colorectal, prostate and lung cancer
Aged: 18–79 years
Patients during or after treatmentHome-based or outdoors, supervised or unsupervisedExercise modalities included walking, cycling, strength training, swimming, stability training and elliptical training ranging from twice a week to five times a week. The duration ranged from 3 weeks to 16 months.EORTC-QLQ, FACT-An, FACT-B, FACT-C, FACT-G, FACT-P, SF-36, MCS/PCSExercise has a direct positive impact on the QoL of patients with cancer, during and following medical intervention.
Huang et al 27 Meta-analysis to evaluate the benefits of mindfulness-based stress reduction on psychological distress among breast cancer survivors9 studies/4 RCTs964 breast cancer survivors
812 patients participated in the RCTs
Mean age range: 49–57.5
Women diagnosed with breast cancerSetting not specified8-week mindfulness-based stress reduction programme
One study used a 6-week formula.
FACT-BMindfulness-based stress reduction programmes showed a positive effect in improving psychological function and overall QoL of breast cancer survivors.
Khan et al 8 To assess the effects of organised multidisciplinary rehabilitation during follow-up in women treated for breast cancer2 RCTs262 patients with breast cancer after treatment
All women were older than 49 years except for two.
At least 12 months after completion of definitive cancer treatmentGroup-based inpatient programme or inpatient programme together with a home-based programmeMultidisciplinary rehabilitation programme incorporating medical input, psychology and physiotherapy or psychology-based education, exercise, peer support group activity and medical input
Duration: 3–10 weeks of 3 sessions per week
Local QoL measure, EORTC QLQ-C30There was ‘low level’ evidence that multidisciplinary rehabilitation can improve QoL over 12 months.
It was not possible to suggest optimal frequency, or one type of intervention over another.
McAlpine et al 15 To examine the evidence-based literature surrounding the use of online resources for adult patients with cancer14 studies/9 RCTs2351 patients with lung, prostate, breast, head and neck and mixed cancer
The sample size for the RCTs was 1121 patients and their mean age ranged from 49.5 to 67.2 years.
Survivors are defined as patients who have had a cancer diagnosis in the past, including those currently receiving active treatment, those in remission or cured, and those who are in the terminal stages of disease.A variety of online platforms were used, including email, online educational resources, online support groups or message boards, cancer information websites and interactive websites.Three interventions: (1) linking patients to their treating team of clinicians,
(2) connecting patients with each other,
(3) educational resources
Duration: 4 weeks to 12 months
FACT-B, SF-12, EORTC QLQ-C30, EQ-5D, EPIC-26, 15DHRQoL, bespoke QoL measureThe overall benefit of online interventions for patients with cancer is unclear.
Although there is significant promise, the few interventions that have been rigorously analysed demonstrate mixed efficacy, often of limited duration.
Mewes et al 18 To systematically review the evidence on the effectiveness of multidimensional rehabilitation programme for cancer survivors and to critically review the cost-effectiveness studies of cancer rehabilitation16 studies originated from 11 trials (11 RCTs, 3 pretest–post-test, 1 quasi-experimental, 1 longitudinal)2175 patients with mixed cancer, predominantly breast
RCTs included from 21 to 199 participants
Age range not specified
Patients with any type of cancer who finished primary treatment with an expected survival duration of at least 1 year
Hormone therapy could still be ongoing.
Face to face in an inpatient settingMultidimensional rehabilitation defined as consisting of two or more rehabilitation interventions directed at the ICF dimensions
Interventions typically included exercise, CBT, psychotherapy, education and return to work interventions.
Programme duration: 4–15 weeks
EORTC QLQ-C30, RAND-36, FACT-G, FACT-B, SF-12Effect sizes for QoL were in the range of −0.12 (95% CI −0.45 to −0.20) to 0.98 (95% CI 0.69 to 1.29).
Multidimensional and monodimensional interventions were equally effective.
Mishra et al 12 To evaluate the effectiveness of exercise on overall HRQoL and HRQoL domains among adult post-treatment cancer survivors40 trials/38 RCTs3694 patients with mixed cancer during and post-treatment were randomised. Over 50% included patients with breast cancer only.
Mean age range: 39–68 years
Participants who have completed treatmentSettings included a gym, community centre, yoga studio, or university or hospital facility. Home-based interventions were included.Exercise was defined as physical activity causing an increase in energy expenditure in a systematic manner in terms of frequency, intensity and duration.
Interventions included prescribed, active exercise formats of aerobic, resistance, stretching or aerobic/resistance combinations.
Some interventions included modules in psychological or behavioural education.
Duration ranged from 3 weeks to 1 year. Frequency varied from daily to once per week. Sessions lasted from 20 to more than 90 min.
EORTC QLQ-C30, FACT-G, FACT-B, FACT-F, FACT-An, FACT-Lym, FACIT-F, CARES-SF, QoL Index, SF-36, Neck Dissection Impairment Index for QoL for head and neck cancer survivorsExercise has a positive impact on QoL with improvements in global QoL.
Osborn et al 17 To investigate the effects of CBT and patient education (PE) on commonly reported problems (ie, depression, anxiety, pain, physical functioning and quality of life) in adult cancer survivors15 RCTs1492 patients with mixed cancer
Age range: 18–84 years
Defined as beyond the time of diagnosisIn a group or individually, face to faceInterventions included group or individual CBT, PE.
CBT intervention duration ranged from 3 to 55 weeks. Frequency varied from 1 hour per week to 2 hours per week.
PE duration ranged from one 20 min session to six weekly 1 hour sessions.
FACTQoL was improved at short-term and long -term follow-up after CBT.
PE was not related to improved outcomes. Individual interventions were more effective than group.
Smits et al 21 To evaluate the effectiveness of lifestyle intervention in improving QoL of endometrial and ovarian cancer survivors8 studies/3 RCTs413 survivors of endometrial and ovarian cancer were included in the analysis. 153 survivors were included in the RCTs. Age range was not specified.Adults diagnosed with endometrial cancer having completed primary treatment (surgery, chemotherapy or radiotherapy)Home-based, individually or group-basedPhysical activity, behavioural change, nutritional, counselling interventions
The duration varied from 12 weeks to 12 months.
FACT-G, FACT-F, FACT-O, SF-36 and QLACSThe review did not show improvements in global QoL. The authors concluded that lifestyle interventions have the potential to improve QoL in this population.
Spark et al 25 To determine the proportion of physical activity and/or dietary intervention trials in breast cancer survivors that assessed postintervention maintenance of outcomes, the proportion of trials that achieved successful postintervention maintenance of outcomes, and the sample, intervention and methodological characteristics common among trials that achieved successful postintervention maintenance of outcomes16 studies originated from 10 RCTs1536 breast cancer survivors during or after treatment
Age range not specified
Not specifiedInterventions included face-to-face contact, printed information and telephone counselling or home-based delivery.Interventions were described as physical activity and/or dietary behaviour change aiming to increase aerobic fitness, strength and physical activity.
Most interventions lasted 1–4 months, with some lasting longer than 6 months.
Measures not specifiedMore research is needed to identify the best ways of supporting survivors to make and maintain these lifestyle changes. QoL-specific outcomes from three studies were not reported.
Spence et al 16 To summarise the literature on the health effects of exercise during cancer rehabilitation and to evaluate the methodological rigour of studies in this area13 studies originated from 10 trials, 4 of which were RCTs327 patients with mixed cancer, mostly patients with breast cancer
The sample size for the RCTs was 245 patients and their mean age ranged from 18 to 65 years.
Patients who had recently completed treatment and had reported no plans for additional treatment
‘Recently completed’ was defined as having completed treatment no more than 12 months prior to enrolment.
Interventions were either supervised exercise programmes or home-based, unsupervised exercise programmes.
One study employed exercise physiologists to prescribe individually tailored exercise programmes.
Most interventions were aerobic or resistance-training exercise programmes.
Most studies prescribed cycling or walking ergometers for the aerobic component. Studies incorporating resistance training prescribed either exercises using machines or resistance bands.
Duration varied from 2 weeks to 14 weeks with a frequency of daily exercise to two or three sessions per week.
Cancer Rehabilitation Evaluation SystemThe findings from this review suggest that exercise can provide a variety of benefits for cancer survivors during the rehabilitation period, including an improved QoL.
Zachariae and O’Toole22 To evaluate the effectiveness of expressive writing for improving psychological and physical health in patients with cancer and survivors16 RCTs1797 patients with cancer or survivors
Breast cancer, ovarian, renal, prostate, colorectal and mixed cancers
Age range not specified
Not specifiedLab or home-basedExpressive writing interventions requiring participants to disclose their emotions in sessions
The duration of the intervention ranged from 3 to 4 sessions, which were daily, weekly or biweekly.
FACT-B, FACT-G, FACT-BMT, QLQ-C30The review did not support the general effectiveness of expressive writing in patients with cancer and survivors.
Zeng et al 26 To examine the effectiveness of exercise intervention on the quality of life of breast cancer survivors25 studies included in the qualitative synthesis, 19 studies included in meta-analysis
22 RCTs
1073 patients with breast cancer aged 18 years or overIndividuals who had completed active cancer treatmentFace to face, by telephoneInterventions included any type of exercise— aerobic, resistance or combination of aerobic and resistance, yoga, tai chi, aerobic and strength training, aerobic and resistance training and stretching.
The duration of the intervention ranged from 4 to 52 weeks.
Time per session varied from 15 to 90 min, 1–5 times per week.
Generic QoL measures: SF-36, FACT-G, EORTC-QLQ-C30
Cancer site-specific QoL measures: FACT-B, EORTC QLQ BR23
The review found consistent positive effects of exercise interventions in overall QoL and certain QoL domains. There was a small to moderate effect of interventions on site-specific QoL. Single type of exercise intervention, general aerobic, yoga or tai chi had significant differences in QoL score changes.
  • 15DHRQoL, 15 Dimensional Health Related Quality of Life; ABS, Affects Balance Scale; CARES, Cancer Rehabilitation Evaluation System; CARES-SF, Cancer Rehabilitation Evaluation System Short Form; CBT, cognitive behavioural therapy; EORTC QLQ BR23, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Breast Cancer Module; EORTC QLQ-C30, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; EORTC QLQ-C33, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C33; EPIC, Expanded Prostate Cancer Index Composite; EPIC-26, Expanded Prostate Cancer Index Composite Short Form; EQ-5D, EuroQol-5D ‘feeling thermometer’; FACIT-F, Functional Assessment of Chronic Illness—Fatigue; FACIT-Sp, Functional Assessment of Chronic Illness—Spiritual Well-Being; FACT H&N, Functional Assessment of Cancer Therapy—Head & Neck; FACT-An, Functional Assessment of Cancer Therapy—Anaemia Scale; FACT-B, Functional Assessment of Cancer Therapy—Breast Cancer; FACT-BMT, Functional Assessment of Cancer Therapy-Bone Marrow Transplant; FACT-C, Functional Assessment of Cancer Therapy—Colorectal; FACT-F, Functional Assessment of Cancer Therapy—Fatigue; FACT-G, Functional Assessment of Cancer Therapy—General; FACTIT, Functional Assessment of Chronic Illness Therapy; FACT-Lym, Functional Assessment of Cancer Therapy—Lymphoma; FACT-O, Functional Assessment of Cancer Therapy—Ovarian; FACT-P, Functional Assessment of Cancer Therapy—Prostate; FLIC, Functional Living Index for Cancer; GHQ, General Health Questionnaire; HRQoL, Health-related quality of life; ICF, International Classification of Functioning, Disability and Health; IFS-CA, Inventory of Functional Status—Cancer; MCS/PCS, Mental Component Score/Physical Component Score; MET, Metabolic Equivalents of Task; NHP, Nottingham Health Profile; PCa-QoL, Prostate Cancer Quality of Life Instrument; QLACS, Quality of Life in Adult Cancer Survivors; QLI, Quality of Life Index; QLQ-PR25, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Prostate Module; QoL, quality of life; QoL-BC, Quality of Life Questionnaire—Breast Cancer; QoQ-C33, European Organisation for Research and Treatment of Cancer (EORTC)-Qualify of LIfe Questionnaire Core 33; RAND-36, 36-Item Short Form Health Survey; RCT, randomised controlled trial; SDS, Symptom Distress Scale; SF-12, Medical Outcomes Study Short-Form Health Survey 12; SF-36, Medical Outcomes Study Short-Form Health Survey 36; SIP, Sickness Impact Profile; UCLA-PCI, University of California, Los Angeles, Prostate Cancer Index; VAS, Visual Analogue Scale; WHOQOL-BREF, WHO Health Organisation Quality of Life Assessment.