Introduction
Cancer is the second worldwide cause of death, and in 2024, 2,001,140 new cancer cases and 611,720 cancer deaths are estimated to occur in the USA [
1]. Despite the high morbidity and mortality rates of several types of cancer, the number of survivors is increasing due to advances in early cancer detection protocols and treatments [
2]. In this regard, there is an increasing focus on strategies to enhance not only survival rates but also health-related quality of life (HRQoL) and life satisfaction variables in patients with cancer throughout their lifespan. This is especially important due to the diagnosis is often perceived as an emotional trauma that declines patients’ life satisfaction and induces pessimistic expectations about the future [
3]. The decline of overall life satisfaction in persons diagnosed with cancer is aggravated by the associated symptoms of the different types of cancer and the side effects of the most-common treatments [
4], including nausea and vomiting [
5], diarrhoea [
6], sleep disorders [
7] and hair loss [
8] in the short term and cardiovascular disease [
9], sarcopenia [
10], cachexia [
11] and loss of muscle function and physical function [
12] in the long term. Additionally, cancer itself and the treatments employed can also cause other drawbacks as increased fear of death [
13] or demoralization [
14]. Furthermore, cancer diagnosis is associated with the occurrence of distress [
15], less self-esteem [
16], depression [
17], anxiety [
17], pain [
18] and cancer-related fatigue [
19]. These side effects are negatively correlated with patients’ HRQoL [
12], suggesting that cancer is an illness that may influence overall life satisfaction in the years and decades following the diagnosis [
20]. Thus, life satisfaction is an important measure of HRQoL and is prospectively related to physical and mental health variables.
Life satisfaction can be defined as an overall evaluation of a person’s HRQoL according to his or her chosen criteria, being a cognitive and critical process [
21] in which subjects compare their real life with their ideal life [
22]. In patients diagnosed with cancer, life satisfaction may be severally compromised at the beginning of the illness as the well-known negative consequences of cancer ward off patients from an ideal life. Interestingly, some domains of life satisfaction such as social relationships may improve following cancer diagnosis consistent with the concept of the disability paradox, wherein patients demonstrate a capacity for a hedonic adaptation, enabling them to mitigate some of the psychological impact of the diagnosis [
23]. Enhancing life satisfaction in healthy and diseased individuals is a crucial variable due to low levels of life satisfaction have been associated with an increased risk of death [
24] and a higher risk of suicide [
25]. In this sense, the suicide rate of persons with cancer is 1.50 to 1.70 times higher than that in the general population [
26]. Overall, scientific evidence suggests that better life satisfaction ratings may positively impact both longevity and HRQoL, particularly in populations that have experienced a recent trauma [
3,
24,
27]. For all these reasons, it seems necessary to search strategies for improving life satisfaction among people with cancer as it may have a direct impact on improving prognosis in the short and long term [
28].
The link between life satisfaction and HRQoL has been previously studied [
27]. However, although there is evidence about the potential effects of regular physical exercise on HRQoL [
29‐
32], its effects on life satisfaction are less clear. In this sense, there are systematic reviews and meta-analyses showing that exercise can improve HRQoL of individuals diagnosed with cancer [
29‐
32]. Regarding the modality of physical exercise, it has been found that both aerobic exercise and resistance exercise seem to be effective in improving HRQoL in individuals diagnosed with cancer [
29,
32]. Additionally, there is evidence suggesting that high-intensity exercise may also be effective in enhancing overall HRQoL in individuals diagnosed with cancer [
30,
32]. The potential effect of exercise to enhance HRQoL has been investigated across various cohorts of cancer, such as patients with prostate [
29], breast [
31] or lung cancer [
32], among others, which suggests effectiveness of exercise to improve quality of life independently of the type of cancer. Consequently, contemporary clinical perspectives for the treatment of cancer consider exercise programs as an adjunctive therapeutic approach to enhance HRQoL in patients with cancer. However, the life satisfaction variable includes other psychological aspects beyond the perception of health and, to our knowledge, there are no systematic reviews or meta-analyses aimed to evaluate the effects of exercise on the life satisfaction of individuals diagnosed with cancer.
In other populations, such as people of advanced age, empirical evidence suggests that physical exercise could have a significant effect on improving life satisfaction [
33]. In people with cancer, higher levels of physical activity (defined as any bodily movement produced by skeletal muscles that results in energy expenditure [
34]) are associated with higher levels of life satisfaction [
35]. Nevertheless, the link between physical exercise, understood as a subset of physical activity that is planned and structured to obtain an improvement of physical fitness [
34], the evidence is unclear regarding its effect on improving life satisfaction in people with cancer. Previous meta-analyses and systematic reviews showed that exercise could reduce depression in patients with breast cancer [
36] and anxiety symptoms in patients with breast, prostate, gynaecologic, haematologic and other types of cancer [
37]. Other potential benefits of physical exercise in these patients are the reduction of cancer-related fatigue [
38] and pain [
39], as well as the enhancement of self-esteem [
40]. So, although some variables associated with life satisfaction have been shown to be improved with exercise in patients with cancer, the overall effect of regular exercise on life satisfaction has not been properly concluded.
All the mentioned evidence suggests a potential effectiveness of regular exercise on the life satisfaction of persons diagnosed with cancer, but, to the authors’ knowledge, there is a lack of meta-analyses and systematic reviews analysing this. For this reason, the aim of the present systematic review and meta-analysis was to analyse the effects of physical exercise programs on life satisfaction in persons with cancer and individuals who have overcome cancer. Based on the previously documented effectiveness of regular exercise, it was hypothesized that a program of regular exercise would improve life satisfaction in persons with cancer and individuals who have overcome cancer.
Discussion
The aim of the present systematic review and meta-analysis was to analyse the effects of physical exercise programs on life satisfaction in patients and survivors of cancer. The main finding was that physical exercise interventions of between 10 and 48 weeks, with a session length of between 15 and 90 min, an intensity of between 40 and 80% HRmax in aerobic exercise and an intensity of between 40 and 70%1RM in resistance exercise, could improve overall life satisfaction in individuals with cancer and persons who have overcome cancer. This outcome was obtained from the meta-analysis of six controlled trials that compared an exercise intervention in patients and survivors of different typologies of cancer with a group of patients with similar characteristics that received only the usual care for cancer. Out of the six controlled trials included in the meta-analysis, five showed higher mean values of life satisfaction after the exercise program or higher improvements in life satisfaction ratings between pre- and post-exercise program measurements with respect to the non-exercise intervention control group. However, only three of them demonstrated statistically significant differences. Additionally, only one of the trials [
55] showed higher mean values of post-intervention life satisfaction in the control group than in the exercise group, although without significant differences. The result of this latter trial [
55] can be explained by the circumstance that, despite being a randomised study, there were significantly higher pre-intervention life satisfaction values in the control group than in the exercise group. Overall, despite a certain variability in the results of the studies included in this meta-analysis, the positive results for life satisfaction found in the patients with cancer enrolled in the exercise programs and the large effect size might suggest that a program of physical exercise could be an effective tool to improve life satisfaction in individuals with cancer and in persons who have overcome cancer. Hence, health and physical exercise professionals working with these persons may consider setting up a program of physical exercise to enhance low-life satisfaction. This may be a convenient strategy to improve the overall status of people diagnosed with cancer as exercise has been deemed as effective to enhance HRQoL [
30], in addition to the potential improvements in life satisfaction reported here.
The quality of the trials, which included an appropriate sample size for each group and standardizations to allow a comparison between groups that only differed in the exercise intervention, reinforced the results about the potential effect of regular exercise on improving life satisfaction in persons diagnosed with cancer. This outcome is in agreement with other meta-analyses indicating that exercise programs could improve life satisfaction in healthy people [
56]. In terms of the possible relationship between life satisfaction ratings and HRQoL, the present results are in line with those of other meta-analyses indicating that physical exercise programs significantly could improve HRQoL in individuals with cancer and persons who have overcome cancer [
29‐
32]. Thus, setting a program of exercise might improve life satisfaction in people diagnosed with cancer, and it may be a co-adjutant of other therapies to improve the prognosis of the illness and reduce mortality [
28]. Several mechanisms could explain the potential positive effect of an exercise program on life satisfaction in persons diagnosed with cancer as regular exercise contributes to the reduction of stress [
37], symptoms of depression and anxiety [
37], sleep disorders [
37], cancer-related fatigue [
38] and pain [
39]; and improves self-esteem [
40], body image [
37] and social functioning [
37]. All of these benefits of exercise in individuals diagnosed with cancer may contribute to an increase in life satisfaction although further investigation is needed to determine which of these factors contributes more to an overall enhancement of life satisfaction in these individuals. This potential improvement in perceived life satisfaction with exercise may be particularly relevant because of the severe negative effects caused by the disease and its treatments, which could lead to reduced life satisfaction after diagnosis [
20]. Improving life satisfaction could be important in these patients because of its relationship with lower levels of symptoms of depression and anxiety [
57], and with a decreased risk of suicide [
25,
26]. In addition, improved life satisfaction could be associated with better acceptance of the disease [
58] and better survival prognosis in patients with cancer [
28].
The current meta-analysis included aerobic, resistance and combined aerobic and resistance exercise interventions. Both exercise modalities may lead to certain benefits in persons diagnosed with cancer that could be related to improvements in life satisfaction. On the one hand, resistance exercise may increase muscle mass [
59], strength [
59] and muscle power [
60], which may be especially important among patients undergoing cancer treatments, such as chemotherapy, as these treatments may negatively affect muscle strength and muscle power [
61]. Furthermore, these positive effects of resistance exercise may be associated with a decrease in cancer-related fatigue [
60], which could indirectly contribute to an increase in patient’s life satisfaction [
62]. On the other hand, aerobic exercise has benefits including the reduction of common symptoms such as pain, insomnia, fatigue and dyspnoea [
63]. In addition, dyspnoea caused by treatments could lead to symptoms of stress and depression [
64]. Therefore, the reduction of all these symptoms through aerobic exercise might lead to an improvement in patients’ life satisfaction. Thus, both aerobic and resistance exercise could contribute to the improvement of life satisfaction in individuals diagnosed with cancer.
Due to the small number of articles included in this meta-analysis, it was not possible to create subgroups according to exercise modality. Thus, further research is needed to find out which type of exercise is the most effective in order to improve patients’ life satisfaction. In this sense, the interventions included in the present meta-analysis were very heterogeneous and included running, walking, cycling, swimming, resistance exercise or dancing. Among all these types, the two interventions with the largest effect sizes involved dance interventions (belly dance and Greek traditional dance). In other populations, such as older adults, it has also been shown that dance could be an interesting strategy to improve life satisfaction [
65]. Therefore, aerobic dance-based exercise may be an interesting strategy to improve life satisfaction in cancer individuals with cancer and survivors. However, this statement should be taken with caution, as only two of the studies included in the present meta-analysis involved dance. Thus, more research is needed to study the effect of dance on life satisfaction in persons diagnosed with cancer. Another consideration is that a substantial proportion of the studies included in the review focused on interventions administered to patients diagnosed with breast cancer. Consequently, further research with patients affected by other types of cancer is warranted to improve understanding of the potential effectiveness of exercise interventions to improve life satisfaction, specifically tailored to different types of cancer.
The main limitation of the present meta-analysis is that the number of trials studying whether physical exercise programs improve life satisfaction in persons with cancer and individuals who have overcome cancer is low. Only six articles were included in the present systematic review and meta-analysis. In addition, one of the included studies was not randomised [
54], and another one presented relevant baseline differences in life satisfaction [
55], which reduced the overall effect size reported in the meta-analysis. Although five of the six included articles showed higher values of life satisfaction after the exercise programme, only three of them showed statistically significant differences. Hence, a notable limitation of the current meta-analysis is the variability of the results between the included studies. Furthermore, it is crucial to highlight the considerable heterogeneity observed among the studies included in the meta-analysis, which may explain the variability among the results. This heterogeneity is manifested in several aspects, including the diversity of the studied populations, as both patients with cancer and survivors of cancer have been included. Moreover, the type of cancer of the participants is not consistent, as interventions based on different types of cancer have been included. In addition, the types of exercise in the programmes are not heterogeneous, with different types of exercise modalities. Based on the results of the current study, a greater number of interventions are needed to identify the most suitable exercise type to improve life satisfaction. In addition, there is a need for higher quality research (randomised controlled trials) with similar baseline values for the life satisfaction variable and with control and experimental groups only differing in whether they take part in the exercise intervention. Another limitation is that most participants in the included studies were women, so the findings of the present review may be more applicable to females, without knowing whether they may be extrapolated to male individuals. In this regard, if the meta-analysis was conducted exclusively with the five articles comprising only female participants, the size of the effect of exercise on life satisfaction would be even amplified, increasing the SMD of the exercise-control comparison from of 1.10 to 1.39. Further investigation is warranted to ensure that the effect of exercise on life satisfaction in individuals with cancer is comparable in men and women. Last, another limitation of the current meta-analysis is that none of the included articles focused on a particular ethnic group. In this sense, it would be interesting to conduct future scientific research focused on analysing the impact of physical exercise on individuals diagnosed with cancer from diverse ethnic backgrounds.
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