Barriers to Increasing Physical Activity Among Young Adult Cancer Survivors

Introduction

Cancer survivorship is often fraught with medical and psychosocial risks for young adult cancer survivors. The medical risks may include ongoing fatigue, ¹ treatment-related weight gain, ² increased likelihood of cardiovascular disease,^3,4 and risk of cancer recurrence or second malignancy.^5,6 In addition, young survivors report higher levels of anxiety and depression than older survivors.^7,8

Some of these long-term physical and mental health risks may be reduced by adopting healthy behaviors. For example, physical activity: facilitates weight management, ⁹ decreases fatigue among cancer survivors,^10,11 improves cardiovascular fitness among survivors, ¹¹ reduces the risk of cancer recurrence (for some cancers), ¹² and improves mood among cancer survivors. ¹³ Unfortunately, population-based data indicate that only approximately 40% of young adult cancer survivors in the United States engage in regular physical activity. ¹⁴ This suggests that the majority of young survivors are either unaware of the benefits of physical activity or face obstacles to becoming more physically active.

One qualitative study shed light on the latter possibility; young adult cancer survivors articulated a number of potential (i.e., anticipated) barriers they believed would hamper their efforts to become more physically active. These included fatigue, time constraints, the weather, and limited sunlight during wintertime. ¹⁵ Given the paucity of research on young survivors, however, data have not yet been reported on the actual physical activity barriers they experience.

The primary aim of this study, therefore, was to identify the types of barriers young adult cancer survivors face when attempting to become more physically active. An exploratory aim was to examine the impact of specific types of barriers on subsequent levels of physical activity. A better understanding of the barriers that make it difficult for young survivors to become more active is key to developing effective interventions for this population. To identify actual barriers to exercise, data were analyzed from the Survivors RENEW Study (RENEW), a randomized controlled pilot study of a physical activity and mindfulness meditation intervention for young adult cancer survivors. ¹⁶

Methods

The protocol for RENEW was approved by the Miriam Hospital Institutional Review Board (IRB) and protocol for this study by William James College IRB. Participant eligibility and recruitment have been described elsewhere, ¹⁶ but are briefly summarized as follows. Cancer survivors were eligible for RENEW if their responses to a screening measure indicated that they were: age 18–39, diagnosed with cancer when 18–39, diagnosed in the past 10 years (i.e., more likely to still be experiencing the effects of diagnosis/treatment), in a cancer remission, completed treatment, and not engaging in regular physical activity or a structured relaxation activity. Exclusion criteria included any psychiatric or medical condition that would make participation dangerous or very difficult. Young survivors who appeared to meet eligibility criteria were asked to provide the name of a physician who could confirm their remission status and that it was safe for them to participate.

Once enrolled in the RENEW trial, participants were randomized to receive a 12-week home-based physical activity and meditation intervention immediately (Intervention group) or after a 12-week delay (Control group). The physical activity component involved setting and pursuing weekly goals to gradually increase the duration and frequency of moderate intensity activity (equivalent to brisk walking). Participants were encouraged to aim for a final goal of exercising five days/week for at least 30 minutes/day, consistent with US recommendations. ¹⁷ The meditation component involved practicing mindfulness meditation four times/week by listening to a mindfulness CD.

During the 12-week intervention, each participant spoke weekly, by phone, with an experienced behavioral coach. The coach reviewed the participant's progress over the past week. If the participant had not met their weekly exercise or meditation goal, the coach read a list of common barriers and asked the participant to identify which had interfered. If a participant reported a barrier that was not on the list, the coach recorded the barrier as described. (In some cases this led to the creation of a new barrier category and in others the research team was able to recode the barrier into an existing category.) The coach then helped the participant to problem-solve ways to overcome the relevant barrier(s). Coaching was based on the principles of social cognitive theory ¹⁸ and the transtheoretical model. ¹⁹ Additional information about the methods and results of the RENEW study is reported in Rabin et al. (2016). ¹⁶

Results

Thirty-eight young adult cancer survivors enrolled in RENEW. Before randomization, one participant withdrew due to loss of interest and two became ineligible (e.g., became too physically active). The remaining 35 participants were randomized to the Intervention group (n = 19) or Control group (n = 16; Fig. 1). Sample characteristics are detailed in Table 1.

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FIG. 1.

Flow of participants through the RENEW Study.

Of the 35 randomized participants, 8 (i.e., 23%) withdrew from the study. The following reasons were cited for withdrawal: became too busy (25%; n = 2), medical issues, including cancer recurrence (37.5%; n = 3), and lost interest in the study or stopped responding to messages (37.5%; n = 3). In addition, the participation of two participants was temporarily suspended due to unplanned pregnancies. [Note that a series of t-test and chi-square analyses were conducted to compare study completers and dropouts; no significant differences were found between groups (i.e., p's > 0.05) on demographic characteristics or baseline levels of physical activity.]

Participants identified a variety of barriers that interfered with weekly physical activity goals. Descriptive analyses were conducted on the barriers reported by the 32 participants who received some or all of the intervention. (Three study noncompleters withdrew before receiving any intervention calls and were, therefore, excluded from analyses.) The percentage of participants reporting each type of barrier at least once and the mean number of times participants reported each type of barrier are detailed in Table 2. A majority of participants (62.5%) identified competing family or work demands as a barrier to physical activity at least once during the intervention. Likewise, 50% of participants identified a more general lack of time as a barrier at least once. Health issues (43.8%) and pain (28.1%) were also identified as barriers by several participants.

An exploratory regression analysis was conducted to provide preliminary insight into the impact of different types of barriers on postintervention levels of physical activity. This analysis used data from the 27 participants who completed a postintervention Seven Day PAR. Findings showed a trend toward significance and indicated that the frequency of reporting schedule-related, health-related, psychological, and weather-related barriers explained 27% of the variance in postintervention physical activity (R² = 0.27, F(4, 23) = 2.08, p = 0.12). There was a trend toward significance for frequency of health-related barriers (β = −0.36, p = 0.07) [but not schedule-related (β = −0.27, p = 0.17), psychological (β = −0.21, p = 0.30), or weather-related (β = 0.24, p = 0.27) barriers] predicting lower levels of postintervention physical activity.

Discussion

The findings from this study indicate that a variety of factors make it difficult for young adult cancer survivors to become more physically active even in the context of a behavioral intervention. One key obstacle is limited time. Of those withdrawing from the study, 25% reported being “too busy” and some of those who did not provide a reason for withdrawal may have felt similarly. Likewise, many participants reported that limited time and competing demands interfered with their ability to meet weekly exercise goals. This is consistent with prior research indicating that being too busy is one of the top barriers to exercise among breast, prostate, and colorectal cancer survivors.^23,24 Younger survivors may be particularly likely to face time constraints, given the personal and professional demands of young adulthood. Participants in the RENEW study described juggling the demands of caring for aging parents, attending to the needs of their children, and keeping up with a demanding work schedule.

Health-related issues also made it difficult for participants to increase their physical activity. Over one-third of those withdrawing from the study cited medical reasons and two participants had to temporarily suspend participation when they became pregnant. Likewise, pain, fatigue, and other health issues (e.g., back injury, viruses, and preparing for medical procedures) made it difficult for several participants to meet weekly exercise goals. The findings from the exploratory analysis indicated that health-related barriers (many of which resolved during the intervention) had an enduring impact: there was a trend suggesting that those who encountered more health-related barriers during the intervention performed less physical activity postintervention. Additional research is needed to confirm and clarify this relationship. Perhaps even resolved health issues have a persistent effect by preventing young survivors from establishing a regular exercise routine. Prior research also indicated that fatigue and other health-related barriers (e.g., flu and back injury) are impediments to cancer survivors participating in an exercise intervention. ²⁴

In addition, participants reported that psychological factors (e.g., lack of motivation and emotional distress) made it difficult to meet weekly physical activity goals. Although older cancer survivors have described similar barriers to exercise, ²³ it is possible that young adults—who may be less likely to be in stable long-term relationships—are more vulnerable to derailment by distressing events.

Thus, although young adult cancer survivors face many of the same barriers to exercise faced by older survivors, they also have some unique challenges. For example, unexpected pregnancy uniquely impacts this demographic. Likewise, young survivors may have even more demands on their time than older survivors, as they are often juggling multiple roles (e.g., building careers, raising children, and caring for aging parents). In addition, some may still be experiencing lingering fatigue or emotional distress consequent to their diagnosis and treatment. These factors provide a difficult context in which to make lifestyle changes.

This study is one of the first to examine the barriers experienced by young adult cancer survivors who attempt to become more physically active. Study limitations include the small sample size, which likely limited the power to detect significant effects in the exploratory analysis. In addition, as data were collected from participants in a physical activity intervention, findings may not generalize to young survivors attempting to increase physical activity on their own. Nonetheless, this study provides important preliminary information about the barriers that must be addressed by those wishing to help young adult cancer survivors implement this important lifestyle change. Future research should seek to replicate these findings with a larger sample of young survivors. In addition, research on a larger sample could investigate whether physical activity barriers differ by medical or demographic characteristics (e.g., cancer type, marital status, and income). This information would help in tailoring interventions to participants.