Factors that promote or hinder physical activity participation in patients with colorectal cancer: A systematic review

 ©Psy,Soc,&Educ,2017,Vol.9(2)  © Psychology, Socie y, & Educa ion, 2017. Vol. 9(2), pp. 201-226 ISSN 2171-2085 (p in ) / ISSN 1989-709X (online) Doi10.25115/psye. 9i2.698 Fac o s ha p omo e o hinde physical ac i i y pa icipa ion in pa ien s wi h colo ec al cance : A sys ema ic e iew Ma ía ROMERO-ELÍAS, Da id GONZÁLEZ-CUTRE, Vicen e J. BELTRÁN-CARRILLO and Edua do CERVELLÓ Spo Resea ch Cen e , Miguel He nández Uni e si y o Elche, Spain (Recei ed on Ma ch 22, 2017; Accep ed on Ap il 16, 2017) ABSTRACT:Di e en s udies o pa ien s wi h colo ec al cance ha e shown ha physical ac i i y has posi i e physical and psychosocial e ec s. Howe e , mos pa ien s do no comply wi h he ecommended c i e ia o physical ac i i y. The aim o he p esen s udy was o analyze, by means o a sys ema ic e iew o he li e a u e, he ac o s associa ed wi h physical ac i i y pa icipa ion in pa ien s wi h colo ec al cance . Fo his pu pose, we conduc ed a sea ch in he da abases WEB OF SCIENCE, SCOPUS and SPORTDISCUS up o Feb ua y o 2016. A e he selec ion p ocess, 23 ull- ex a icles we e e ained. The esul s allowed iden i ying ou la ge ca ego ies o ac o s ela ed o physical ac i i y pa icipa ion in his popula ion: sociodemog aphic ac o s, heal h ac o s (speci ic and nonspeci ic o he disease), p io expe ience and p e e ences, and mo i a ional ac o s. Among he esul s ob ained, como bidi y and he eceip o adju an he apy (wi h i s co esponding side e ec s, such as a igue and nausea) we e ela ed o less physical ac i i y. Va iables such as posi i e a i ude, amily suppo , sa is ac ion o basic psychological needs, and sel -de e mined mo i a ion we e shown o be acili a o s o physical ac i i y. Taking in o accoun hese esul s, i is necessa y o de elop p og ams o physical ac i i y adap ed o he pa icula cha ac e is ics o his popula ion and based on mo i a ional s a egies ha p omo e adhe ence o physical ac i i y. Keywo ds: physical exe cise, mo i a ion, ba ie s, ea men , heal h Fac o es que p omue en o di icul an la p ác ica de ac i idad ísica en pacien es con cánce colo ec al: Una e isión sis emá ica RESUMEN: Di e en es es udios con pacien es de cánce colo ec al han demos ado que el eje cicio ísico iene e ec os ísicos y psicosociales posi i os. Sin emba go, la mayo ía de pacien es no cumple los c i e ios de ac i idad ísica ecomendados. El obje i o del p esen e es udio ue analiza , a a és de una e isión sis emá ica de la li e a u a, los ac o es asociados con la p ác ica de ac i idad ísica en pacien es con cánce colo ec al. Pa a ello se ealizó una búsqueda en las bases de da os WEB OF SCIENCE, SCOPUS y SPORTDISCUS has a eb e o de 2016. T as el p oceso de selección, se e u ie on 23 a ículos a ex o comple o. Los esul ados pe mi ie on iden i ica cua o g andes ca ego ías de ac o es elacionados con la p ác ica de ac i idad ísica en es a población: ac o es sociodemog á icos, ac o es de salud (especí icos y no especí icos de la en e medad), p e e encias y expe iencias p e ias, y ac o es mo i acionales. En e los esul ados ob enidos, cabe des aca que la como bilidad y la ecepción de e apia adyu an e (con sus co espondien es e ec os secunda ios como Physical ac i i y in pa ien s wi h colo ec al cance  ©Psy,Soc,&Educ,2017,Vol.9(2)  202 a iga y náuseas), se elaciona on con una meno ealización de ac i idad ísica. Va iables como la ac i ud posi i a, el apoyo amilia , la sa is acción de las necesidades psicológicas básicas y la mo i ación au ode e minada, se mos a on como acili ado es de la pa icipación en ac i idad ísica. Teniendo en cuen a es os esul ados, es necesa io desa olla p og amas de ac i idad ísica ajus ados a las ca ac e ís icas pa icula es de es a población y basados en es a egias mo i acionales que a o ezcan la adhe encia a la p ác ica. Palab as cla e: eje cicio ísico, mo i ación, ba e as, a amien o, salud. Co espondence: Da id González-Cu e, Cen o de In es igación del Depo e, Uni e sidad Miguel He nández de Elche, A enida de la Uni e sidad s/n, 03202 Elche (Alican e). E-mail: dgonzalez- [email p o ec ed] INTRODUCTION Cance is cu en ly one o he majo causes o mo ali y wo ldwide. In 2012, he e we e abou 14 million new cases and 8.2 million cance - ela ed dea hs (WHO, 2015). Fo example, cance ep esen s he second cause o dea h in he Uni ed S a es and is expec ed o exceed ca dio ascula disease as he leading cause o dea h in he coming yea s (Siegel, Mille , & Jemal, 2015). I was es ima ed ha 595690 Ame icans would die o cance in 2016, which ansla es in o abou 1630 people pe day (Ame ican Cance Socie y, 2016). In Spain, he es ima ion 2015 was o 227076 cases, wi h an inc ease ha occu s o a g ea e ex en in he popula ion ≥ 65 yea s (Spanish Socie y o Medical Oncology, 2014). App oxima ely 30% o cance dea hs a e ela ed o i e beha io al isk ac o s: high body mass index, low in ake o ui and ege ables, smoking, alcohol consump ion, and lack o physical ac i i y (WHO, 2015). Besides he human su e ing in ol ed in cance , i has been es ima ed ha his disease causes a high economic cos o heal h sys ems. Fo example, he o al cos o cance in 2008 in he Uni ed S a es was a ound $ 228 billion. This si ua ion is a se ious public heal h p oblem, such ha esea ch o he ac o s ha can p e en o alle ia e he disease is a p io i y o go e nmen s (Ame ican Cance Socie y, 2010). Speci ically, in he Uni ed S a es, colo ec al cance is he hi d cause o dea h by cance in men and women, and he second cause when bo h sexes a e combined. In Eu ope, colo ec al cance held he second posi ion in incidence a e b eas cance in 2012, and 49190 dea hs om colo ec al cance we e es ima ed in 2016 (Spanish Ne wo k o Cance Regis e s, 2014). Fi e o en-yea su i al a es o pa ien s wi h colo ec al cance a e 65% and 58%, espec i ely (Siegel e al., 2015). Due o colo ec al cance , pa ien s li e wi h physical and psychological sequelae ha g ow wo se wi h ea men . Some o he symp oms a e: in es inal dys unc ion, su ge y pain, s oma, a igue, muscle weakness, al e a ion o body image, anxie y, and dep ession (Downing e al., 2015; Zabo a, B in zenho eSzoc, Cu bo , Hooke , & Pian adosi, 2001). To alle ia e hese sequelae, he e is inc easingly mo e scien i ic e idence o he physical and psychological bene i s o physical ac i i y, bo h du ing and a e ea men o his disease (Ga cia & Thomson, 2014). Speci ically, in colo ec al cance , i was ound ha egula exe cise and Physical ac i i y in pa ien s wi h colo ec al cance ©Psy,Soc,&Educ,2017,Vol.9(2)  203 imp o ed physical condi ion a e associa ed wi h many indica o s o quali y o li e (Cou neya, F ieden eich, A hu , & Bobick, 1999a; Cou neya e al., 2004; Cou neya, Mackey, & Jones, 2000), wi h a lowe p obabili y o ecu ence (Meye ha d , Hesel ine e al., 2006) and lowe isk o dea h (Meye ha d e al., 2008). In he s udy o Meye ha d , Hesel ine e al. (2006), i was ound ha pa ien s who walked a leas 6 hou s pe week a mode a e in ensi y had a 47% highe chance o su i ing he disease. Ano he s udy (Meye ha d , Gio annucci e al., 2006) wi h 600 women diagnosed wi h colo ec al cance showed ha hose who inc eased hei physical exe cise a e diagnosis had a 52% lowe chance o dying om he disease compa ed wi h hose who we e no exe cising. Howe e , hose who dec eased he amoun o exe cise had a 32% highe chance o dying om he disease. Mo eo e , hose who did physical exe cise equi alen o walking 6 hou s pe week we e mo e likely o ha e a longe li e han hose who did less o no exe cise. In spi e o he desc ibed bene i s, only 35% o colo ec al cance su i o s in he Uni ed S a es pe o m he ecommended physical ac i i y (Blancha d, Cou neya, & S ein, 2008), and 17.1% in Canada (Cou neya, Ka zma zyk, & Bacon, 2008). In addi ion, a ious s udies ca ied ou in Canada (see Vallance & Cou neya, 2012) show ha , a e diagnosis, physical ac i i y dec eases on a e age abou 2 hou s pe week, and only 5-10% o he pa ien s pa icipa e in physical ac i i y du ing ea men , and 20-30% a e ea men . A e o e coming he disease, pa ien s inc ease hei physical ac i i y pa icipa ion bu wi hou eaching he ini ial le els. The e is also a g ea e dec ease o physical ac i i y when combining a ious ea men s such as su ge y, chemo he apy, and adio he apy, in compa ison o ecei ing jus one o hem (I win e al., 2004). Howe e , 80% o he pa ien s eel capable o pa icipa ing in physical ac i i y, and 70% a e in e es ed in i so, in o de o de elop any in e en ion, i is essen ial o know he ac o s ha p omo e o hinde physical ac i i y pa icipa ion in his collec i e (Vallance & Cou neya, 2012). Taking in o accoun ha he e a e al eady plen y o s udies ha ha e analyzed his p oblem in colo ec al cance pa ien s, he aim o his s udy was o pe o m a sys ema ic e iew o mo e clea ly in e p e all he ac o s ela ed o hese pa ien s' pa icipa ion in physical ac i i y. The e a e se e al sys ema ic e iews o he ac o s ela ed o he physical ac i i y pa icipa ion in pa ien s wi h cance , all o hem including di e en ypes o cance (Pa k & Ga ey, 2007). Some au ho s ha e e en sys ema ically analyzed he e ec s o exe cise in pa ien s wi h colo ec al cance (C ame , Lauche, Klose, Dobos, & Langho s , 2014; Kampsho e al., 2014; Husebø, Dy s ad, Sø eide, & B u, 2013). Howe e , o da e he e is no sys ema ic e iew o he ac o s associa ed wi h physical ac i i y pa icipa ion in pa ien s wi h colo ec al cance , so his is he i s one o be pe o med. This e iew is ocused on colo ec al cance because i is he second mos common ype o cance in Eu ope and he Uni ed S a es, and he mos equen in some coun ies like Spain (Spanish Socie y o Medical Oncology, 2014), p esen ing a mode a e su i al a e. Gi en i s high incidence, bu a he same ime i s posi i e p ognosis, we hink ha i is in e es ing o ocus on his ype o cance o mo e speci ically deepen ou knowledge o he ac o s ela ed o he le els o physical ac i i y. In addi ion, he a iables con ibu ing o p edic physical ac i i y Physical ac i i y in pa ien s wi h colo ec al cance  ©Psy,Soc,&Educ,2017,Vol.9(2)  204 appea o a y as a unc ion o he ype o cance , which indica es he need o analyze each one sepa a ely (Vallance & Cou neya, 2012). METHOD Da a sou ces and sea ch e ms The elec onic sea ch was made by means o he WEB OF SCIENCE, SCOPUS and SPORTDISCUS da abases up o Feb ua y o 2016. The sea ches included di e se combina ions o ou se s o e ms: 1) Te ms ela ed o cance : colo ec al cance , cance s age and ea men ; (2) Te ms abou physical ac i i y: physical ac i i y, exe cise and aining; 3) In luen ial ac o s in physical ac i i y pa icipa ion: acili a o s, ba ie s, sociodemog aphic and psychosocial ac o s, mo i a ion and adhe ence; 4) Mo i a ional heo ies: heo y o planned beha io , sel -de e mina ion heo y, sel -e icacy heo y, and socio-ecological model. The comple e sea ch s a egies a e no p esen ed o he sake o b e i y, bu hey can be eques ed om he au ho s. Consul a ion o publica ions and cons uc ion o he ca alogue The selec ion o he s udies ocused on he ac o s associa ed wi h physical ac i i y pa icipa ion in pa ien s wi h colo ec al cance (Figu e 1). We conduc ed wo le els o sc eening. Fi s , we sea ched o combina ions o all he keywo ds in all he da abases, eaching 19213 iden i ied egis e s. Ano he 18 addi ional egis e s we e iden i ied in he e e ences lis s o he a icles, ob aining a o al o 19231 eco dings. We included all he e e ences in he p og am “EndNo e” o de ec duplica es, inding a o al o 15532, which we e dele ed. The e o e, 3699 unique ci a ions emained, om which we excluded 3649 a e eading he abs ac s because hey did no analyze he ela ions be ween physical ac i i y pa icipa ion and colo ec al cance , so ha inally, 50 a icles emained, which we e downloaded in ull ex . We hen es ablished he second sc eening sys em, which consis ed o applying he ollowing exclusion c i e ia: 1) including o he di e en ypes o cance wi hou speci ying he esul s sepa a ely o each one; (2) including o he heal hy beha io s wi hou speci ying he esul s e e ed o physical ac i i y; 3) ocusing on ac o s o s a egies o p omo e physical ac i i y in o de o p e en colo ec al cance , bu wi hou using a sample o pa ien s a ec ed wi h his disease; 4) ocusing only on he e ec s o bene i s o physical ac i i y in his popula ion wi hou co e ing he ac o s ela ed o physical ac i i y pa icipa ion. We elimina ed 27 egis e s o mee ing hese c i e ia, lea ing a o al o 23 inal egis e s in he p esen s udy. Physical ac i i y in pa ien s wi h colo ec al cance ©Psy,Soc,&Educ,2017,Vol.9(2)  205 Figu e 1. Flow cha o he selec ion p ocess o he s udies. Selec ion p ocess and da a ex ac ion The necessa y a iables o analyze he esul s a e g ouped in Table 1. The ollowing da a a e included: e e ences; o al numbe o pa ien s, o men and women; age; cance s age a he momen o he s udy; ea men ; heo e ical amewo k; design; measu e o physical ac i i y; and esul s ela ed o he acili a o s and ba ie s o physical ac i i y pa icipa ion. Cance s age (see oo no e o Table 1), ype o ea men (su ge y, adio he apy, chemo he apy) and whe he o no hey we e ecei ing ea men a he ime o he s udy o i had al eady concluded we e included in his e iew. In addi ion, we indica e he design o he s udies, di iding hem in o c oss-sec ional, longi udinal, expe imen al, and quali a i e. We also aimed o iden i y whe he he s udies a e suppo ed by a heo e ical amewo k, as his would guide in e en ions o p omo e physical ac i i y wi h his collec i e in a mo e s uc u ed way, unde s anding how beha io al change occu s (Biddle, Mu ie, Go ely, & Blamey, 2012). Las ly, we highligh he impo ance o analyzing how physical ac i i y is measu ed, ei he by means o mo e subjec i e measu es like ques ionnai es, o mo e objec i e measu es like accele ome e s. All hese aspec s a e impo an when analyzing he ac o s ha in luence physical ac i i y pa icipa ion in his popula ion. 19213 s udies iden i ied o sc eening 18 addi ional egis e s iden i ied om o he sou ces 15532 duplica e e en s 3699 unique egis e s iden i ied 3649 excluded egis e s 27 ull- ex egis e s excluded: They include o he di e en ypes o cance wi hou speci ying he esul s o each ype. n = 14 They include o he heal hy beha io s wi hou speci ying he esul s e e ing o physical ac i i y.n = 6 S udies o p e en ion o cance by means o physical ac i i y, bu wi hou using a sample o pa ien s wi h his disease. n = 5 They ocus on he e ec s/bene i s o physical ac i i y in his popula ion bu wi hou including he ac o s ela ed o i s p a ici p a ion. n= 2 50 ull- ex a icles analyzed o decide hei eligibili y 23 s udies included in he sys ema ic e iew Physical ac i i y in pa ien s wi h colo ec al cance  ©Psy,Soc,&Educ,2017,Vol.9(2)  206 Table 1. S udies ha Analyze he Fac o s Rela ed o Physical Ac i i y Pa icipa ion in Pa ien s wi h Colo ec al Cance REFERENCES NUMBER OF PATIENTS AGE (yea s) CANCER STAGE TREATMENT THEORETICAL FRAMEWORK DESIGN MEASURE OF PA RESULTS Bu a e al. (2012) 1371 To al 56% males 44% emales ≥ 65 = 69% M = 69.5, SD = 9.7 I = 28% II = 39% III = 28% IV = 5% S = 67.54% RT = 0.07% CT = 1.02% S + RT = 22.90% S + CT = 24.58% S + RT + CT = 6.41% No used C oss- sec ional Eu opean P ospec i e In es iga ion in o Cance (EPIC) Physical Ac i i y Ques ionnai e Being younge , male, employed, no smoking, lowe body mass index, being only in chemo he apy ea men and no ha ing como bidi ies→↑MVPA Chambe s e al. (2009) 978 To al 55.8% males 44.2% emales 20-49 = 7.6% 50-59 = 20.3% 60-69 = 35% ≥ 70 = 37.2% I = 28.7% II = 30.6% III = 25.8% IV = 0.7% No speci ied No used Longi udinal 5, 12, 24 and 36 mon hs pos diagnosis Ac i e Aus alia Su ey ↑Soma iza ion →↓PA ↑Nega i e assessmen o he impac o cance →↓PA ↑Fa igue →↓PA ↑Smoking →↓PA ↑Obesi y →↓PA Chung e al. (2013) 422 To al 63% males 37% emales M = 59.69, SD = 10.87 I = 95 II = 102 III = 103 IV = 16 Un inished = 31.27 % Finished = 68.72 % No used C oss- sec ional Exe cise & Quali y o Li e Ques ionnai e In ea men : Wi hou changes in LPA, MPA and TPA. ↓VPA End o ea men : Wi hou changes in MVPA s. p e- ea men .↑LPA and TPA Cou neya e al. (1999b) 66 To al 57.57% males 42.42% emales M = 60.8, SD = 11.5 I = 6% II = 29% III = 26% IV = 5% Did no ecei e AT = 27.3% RT = 7.6% CT = 46.9% RT + CT = 18% Theo y o planned beha io C oss- sec ional Godin Leisu e Time Exe cise Ques ionnai e (GLEQ) In en ion and p e-diagnosis PA →PA pos ope a ion Cou neya e al. (2004) 102 To al 58.1% males 41.9% emales M = 60.3, SD = 10.4 III–IV = 80.6% S = 100% RT = 20.4% CT = 64.5% Only S = 34.4% S + CT = 46.2% S + RT + CT = 19.4% All pa ien s we e ope a ed in he pas 3 mon hs Theo y o planned beha io Expe imen al Godin Leisu e Time Exe cise Ques ionnai e (GLEQ) Expe imen al g oup: Highe le els o PA, beha io al con ol, lowe wo k s a us, and less adju an ea men →↑PA Con ol g oup: highe le els o PA and mo e in en ion →↑PA Cou neya e al. (2005) 69 To al 56.5% males 43.5% emales < 60 = 39.1% > 60 = 60.9% No speci ied Only S = 39.1% S + CT = 42% S + RT + CT = 18.8% All pa ien s we e ope a ed in he pas 3 mon hs No used Expe imen al Godin Leisu e Time Exe cise Ques ionnai e (GLEQ) Ba ie s: Lack o ime,adju an ea men , side e ec s and a igue Physical ac i i y in pa ien s wi h colo ec al cance ©Psy,Soc,&Educ,2017,Vol.9(2)  207 D’And ea e al. (2014) 2378 To al 18-65 No speci ied No speci ied No used C oss- sec ional USA Na ional Heal h In e iew Su ey Hispanics and non-Hispanic blacks ( s. Whi es) and cu en smoke s →↓PA Highe educa ional le el, ewe ch onic condi ions, cu en d inke s →↑PA Dennis e al. (2013) 444 To al 55% males 45% emales 36-91 (M = 69) ≥ 60 = 80% No speci ied P e- ea men = 12.16% In ea men = 13.96% Comple ed 6 mon hs ago = 15.09% Comple ed mo e han 6 mon hs ago = 40.1% Cance - ee g oup = 18.69% No used C oss- sec ional Li es yle su ey o people wi h colo ec al cance P e e ences: G oup-based PA p og ams Ba ie s: S oma and ea men - ela ed a igue VPA ( om - o +): P e- ea men , in ea men , pos - ea men , < 6 mon hs and > o 6 mon hs pos - ea men and cance - ee g oup Fishe e al. (2016) 478 To al 59% males 41% emales 31-97 (M = 68) No speci ied Finished = 73% No inished = 16% Unknown = 5% No used C oss- sec ional Godin Leisu e Time Exe cise Ques ionnai e (GLEQ) Ba ie s: Fa igue, ageing, and como bidi ies ↑Ba ie s →↓PA Bene i s: imp o emen o physical condi ion, imp o emen o heal h and main enance/weigh loss Hawkes e al. (2015) 410 To al 54% males 46% emales M = 66.3, SD = 10.1 Insu icien PA I = 90.2% II = 85.1% III = 89.1% Su icien PA I = 9.8% II = 14.9% III = 10.9% S = 96% AT = 24% Ecological model o heal h beha io Expe imen al Godin Leisu e Time Exe cise Ques ionnai e (GLEQ) Being e i ed, ha ing p i a e heal h insu ance, ha ing heal hy body weigh , p e-diagnosis physical ac i i y, ha ing a habi , high le el o sel -e icacy, wa ching less TV, high quali y o physical li e, eeling well-being and being a pa o he in e en ion g oup →↑PA pos 12 mon hs Husson e al. (2015) 1643 To al 56.11% males 43.88% emales < 65 = 28.97% 65-75 = 39.07% > 75 = 31.96% I = 30.66% II = 36.33% III = 29.66% IV = 3% Only S = 46.33% S + RT = 24.33% S + CT = 20.66% S + RT + CT = 8.66% Only CT = 1.33% No used Longi udinal Eu opean P ospec i e In es iga ion In o Cance (EPIC) PA Ques ionnai e ↓Knowledge abou heal h →↓PA Kang e al. (2014) 427 To al 63% males 37% emales < 60 = 52.9% ≥ 60 = 47.1% I = 95 II = 102 III = 106 IV = 18 Un inished = 30.9% Finished = 67% No used C oss- sec ional Ques ion abou pa icipa ion o no in PA and whe he o no ecommenda ions o he ACSM a e me Ba ie s ( om + o -): 1s Fa igue 2nd Low physical condi ion 3 d Low heal h s a us 4 h Lack o ime and in o ma ion ↑T ea men →↓PA Physical ac i i y in pa ien s wi h colo ec al cance  ©Psy,Soc,&Educ,2017,Vol.9(2)  208 Lynch e al. (2016) 185 To al 55.14% males 44.86% emales 18-80 (M = 64.2, SD = 10.3) I = 22% II = 28% III = 41% Only S = 57.84% S + AT = 42.16% Adju an he apy inished No used C oss- sec ional Accele ome e Males, mo e como bidi ies, highe BMI and ime slo 6 pm-8 pm →↑Seden a y beha io Women, low educa ional le el and lowe BMI →↑LPA Mo e amily income, being employed, lowe BMI, younge , and ime slo s 4 pm-5 pm and 6 pm- 10 pm →↑MVPA Lynch e al. (2007) 1966 To al 60% males 40% emales 20-49 = 8.5% 50-59 = 19.43% 60-69 = 33.31% 70-80 = 38.25% No speci ied No speci ied No used Longi udinal Ac i e Aus alia Su ey High educa ional le el, no smoking, no a igue →↑PA in males Only su ge y, heal hy BMI, li ing ou side he capi al, no smoking, no a igue →↑PA in women Lynch e al. (2010) Time 1 538 To al 63% males 37% emales Time 2 403 To al 61.5% males 38.5% emales Time 1 20-49 = 8.9% 50-59 = 19.7% 60-69 = 31.1% ≥ 70 = 40.3% Time 2 20-49 = 8.9% 50-59 = 19.4% 60-69 = 29.0% ≥ 70 = 42.7% Time 1 I = 25.5% II = 35% III = 30.6% IV = 8.9% Time 2 I = 26% II = 38% III = 29.4% IV = 7.1% Time 1 S = 56.9% S + AT = 43.1% Time 2 S = 58% S + AT = 41.4% All he pa ien s we e ope a ed in he pas 3 mon hs Ecological model o heal h beha io Longi udinal 5 and 12 mon hs pos - diagnosis No measu ed Ba ie s 5 and 12 mon hs ( om + o -): 1s Cance -speci ic ba ie s 2nd Ba ie s om pe sonal a ibu es 3 d Ba ie s om social en i onmen 4 h Ba ie s om physical en i onmen McGowan, Speed- And ews, Blancha d e al. (2013) 600 To al 58.33% males 41.67% emales < 65 = 39% ≥ 65 = 61% 44% Ea ly s age diagnosis RT = 24% 10% s ill ecei e ea men No used C oss- sec ional Godin Leisu e Time Exe cise Ques ionnai e (GLEQ) Olde , lowe educa ional le el, lowe yea ly income, mo e ime elapsed since diagnosis, ewe elapses, s oma, in ea men and ac i e s. seden a y → ↓ in e es in PA McGowan, Speed- And ews, Rhodes e al. (2013) 600 To al 58.3% males 41.7% emales < 65 = 39% ≥ 65 = 61% M = 67.3 I = 12.6% II = 11.5% III = 21.5% IV = 11.33% Unknown = 43% RT = 24.3% CT = 55.5% No speci ied when hey ecei ed ea men No used C oss- sec ional Ques ions abou ype, equency, and du a ion o PA in he pas mon h Males, ma ied, social o egula d inke s, good heal h and ≥ 5 yea s since he diagnosis →↑PA Mo ielli e al. (2016) 18 To al 66.7% males 33.3% emales 34-73 (M = 57.5) 72% IIIB All ecei ed neoadju an he apy Theo y o planned beha io Expe imen al Godin Leisu e Time Exe cise Ques ionnai e (GLEQ) Bene i s: ca dio ascula endu ance, quali y o li e, sel -es eem, be e physical unc ioning Damage: Fa igue, dia hea, and skin i i a ion Ba ie s: Side e ec s o neoadju an he apy and lack o mo i a ion Physical ac i i y in pa ien s wi h colo ec al cance ©Psy,Soc,&Educ,2017,Vol.9(2)  209 Peddle e al. (2008) 413 To al 54% males 46% emales 20-80 (M = 60, SD = 7.5) 48% did no know cance s age. No hing mo e speci ied CT = 53%. A leas 1 yea ago S = 96%. No speci ied when hey we e ope a ed Sel - de e mina ion heo y C oss- sec ional Godin Leisu e Time Exe cise Ques ionnai e (GLEQ) ↑Educa ional le el, iden i ied and in ojec ed egula ion →↑PA Speed-And ews e al. (2014) 600 To al 58.3% males 41.7% emales 31-92 (M = 67.3) 44.2% Ea ly s age diagnosis RT = 24% CT = 55% Adju an he apy comple ed Theo y o planned beha io C oss- sec ional Ques ion abou le el o physical ac i i y Ba ie s: physical condi ion and heal h s a us, musculoskele al issues and ea men Facili a o s: ha ing ime, doing i wi h o he s, p oximi y o he acili ies Speed-And ews e al. (2012) 600 To al 58.33% males 41.67% emales 31-92 (M = 67.3) < 65 = 39% ≥ 65 = 61% I = 12.66% II = 11.5% III = 21.5% IV = 11.33% Unknown = 43% RT = 24.3% CT = 55.5% Adju an he apy comple ed Theo y o planned beha io C oss- sec ional Godin Leisu e Time Exe cise Ques ionnai e (GLEQ) Being younge , unma ied, highe educa ional and economic le el, employed, no smoke s, social d inke s, no adia ion he apy, disease ee, be e heal h and ewe como bidi ies →↑PA Spence e al. (2011) 10 To al 70% males 30% emales 42-74 (M = 57.8) II = 40% III = 60% Chemo he apy comple ed 4 weeks ago No used Expe imen al Quali a i e Ques ions abou he le el o physical ac i i y: no hing, spo adic (< 3 sessions pe week) o egula (≥ 3 sessions pe week) Bene i s: Sel -es eem, heal hy habi s, posi i i y, in en ion o pe o m PA, lea ning abou he impo ance o PA, physical condi ion, eco e ing le els o ene gy p io o ea men and dec easing a igue. P e e ences: Need o aine supe ision. S a PA 2-4 weeks pos - ea men , bu can also be done du ing ea men , dec easing he in ensi y. Pos -p og am PA: in oduce s eng h aining and e e yone in ends o con inue. an Pu en e al. (2016) 5375 To al Time 1 = 45.6% o he o al Time 2 = 29.32% o he o al Time 3 = 25.58% o he o al 54.6% males 45.5% emales < 55 = 7.6% 55-74 = 60% ≥ 75 = 32.4% M = 69.6, SD = 9.5 I = 31.8% II = 38.6% III = 29.5% Only S = 49.6% S + RT= 23.1% CT= 20.3% S + RT + CT = 7% No used Longi udinal Eu opean P ospec i e In es iga ion in o Cance (EPIC) Physical Ac i i y Ques ionnai e Fa igue, dyspnea, side e ec s o chemo he apy, u ina ion p oblems, loss o appe i e, weigh loss, pain, no so young, wi hou pa ne , obesi y, anxie y, dep ession, wo se quali y o li e and physical unc ioning→ ↓MVPA ↑PA males s. women No e. ↑ = inc ease; ↓ = dec ease; → = ela ion; AT = adju an he apy; S = su ge y; RT = adio he apy; CT = chemo he apy; PA = physical ac i i y; LPA = ligh physical ac i i y; MPA = mode a e physical ac i i y; VPA = igo ous physical ac i i y; MVPA = mode a e and igo ous physical ac i i y; TPA = o al physical ac i i y. S age I: he umo a ec s he wall o he colon o ec um wi hou going h ough he muscula laye . Lymph ganglia no a ec ed. S age II: he umo has in il a ed all he laye s o he wall o he colon o ec um. I can in ade he su ounding o gans. Lymph nodes no obse ably a ec ed. S age III: he cance has in aded he neighbo ing o gans and a ec s he lymph nodes. S age IV: he cance has sp ead o dis an o gans o he colon o ec um, such as li e , lung o bones. Physical ac i i y in pa ien s wi h colo ec al cance  ©Psy,Soc,&Educ,2017,Vol.9(2)  216 Rega ding ime schedule p e e ences o physical ac i i y in colo ec al cance pa ien s, a s udy in Aus alia and Canada, measu ing he le els o ac i i y wi h accele ome e s, has ecen ly been ca ied ou (Lynch e al., 2016). The esul s showed ha he pa ien s we e less seden a y om eigh in he mo ning un il h ee in he a e noon and mo e seden a y om six in he a e noon. The pe cen age o ime pe o ming mode a e- igo ous physical ac i i y was lowe be ween en o'clock in he mo ning and h ee in he a e noon and highe om ou o en in he a e noon. Las ly, Spence e al. (2011) ca ied ou a s udy in Aus alia, analyzing pa ien s' p e e ences a e chemo he apy by means o semis uc u ed in e iews. The pa ien s p e e ed o choose he ype o exe cise and a gym wi h ai condi ioning o egula e body empe a u e and be able o make mo e e o wi hou su e ing om he hea . They also p e e ed o s a he physical ac i i y p og am be ween 2 and 4 weeks a e comple ing chemo he apy because hey hough hey needed ime o eco e om i . Howe e , some p e e ed o s a la e bu o main ain con ac wi h he hospi al du ing his ime o eco e y a e chemo he apy, so as no o lose hei mo i a ion and commi men o he p og am. On ano he hand, hal o he pa ien s claimed ha hey could ha e s a ed he p og am du ing he adju an ea men bu dec easing he in ensi y. In con as , he o he hal said ha his would be e y di icul due o he a igue caused by he ea men and he physical and emo ional ene gy equi ed o o e come hese symp oms. Howe e , almos e e yone belie ed ha i hey had pe o med exe cise du ing ea men , hey would ha e el be e when he ea men was inished. In his s udy, he pa ien s also posi i ely alued he supe ised indi idualized aining, adap ed o hei cha ac e is ics, being able o choose he schedule, place, ype o session, e c. In ac , hey exp essed di icul y o con inue he physical ac i i y p og am wi hou he aine 's suppo and ollow-up. They all conside ed he aine 's supe ision necessa y o achie e g ea e mo i a ion and inc ease hei le els o sel -con idence. Conce ning g oup physical ac i i y, hey hough ha i would be mo e economical, hey would ha e mo e social suppo , and would sha e expe iences. Howe e , mos p e e ed o ca y ou he physical ac i i y p og am indi idually and, i i was done in a g oup, hey p e e ed hei classma es o be cance su i o s o people whose li e had ecen ly been a isk. Las ly, a e he p og am, all he pa icipan s in ended o con inue doing physical ac i i y and p oposed o include s eng h aining and o main ain he le el o ae obic exe cise. They poin ed ou ha i would be di icul o con inue he equency and he in ensi y o he wo kou s wi hou he supe ision o he aine . Mo i a ional ac o s Nex , we p esen he ac o s associa ed wi h he mo i a ional heo ies ha explain human beha io , ying o unde s and which a iables a e ela ed o he physical ac i i y pa icipa ion in his popula ion. On he one hand, some s udies ha e ound highe le els o pe cei ed sel - e icacy in pa ien s who pe o m mo e physical ac i i y (Hawkes e al., 2015). On he o he hand, based on he heo y o planned beha io , Cou neya e al. (1999b) ound ha he in en ion o exe cise and exe cise p e-diagnosis we e ela ed o pos -su ge y exe cise. Mo eo e , he a i ude owa ds exe cise was he only a iable ha co ela ed signi ican ly wi h he in en ion o Physical ac i i y in pa ien s wi h colo ec al cance ©Psy,Soc,&Educ,2017,Vol.9(2)  217 exe cise. F om his same heo y, Mo ielli e al. (2016), ying o unde s and he in luence o p io expec a ions be o e he physical ac i i y p og am, e ealed ha pa ien s pe cei ed exe cise du ing chemo he apy as mo e pleasan and less di icul han an icipa ed. Con inuing wi h he heo y o planned beha io , among he mos equen belie s abou he bene i s o physical ac i i y (beha io al belie s), Speed-And ews e al. (2014) ound ha pa ien s belie ed ha physical ac i i y imp o ed physical i ness, i could imp o e hei well- being and ene gy le els, and hey el be e a e exe cising. Wi h ega d o no ma i e belie s, he mos common belie was ha physical ac i i y should be app o ed by he membe s o he amily, he oncologis s, and one's bes iend. As ega ds con ol belie s, he ac o s ha made hem eel less con iden o being able o o e come ba ie s we e medical o heal h p oblems, pain, and he ac o e u ning o ea men (Speed-And ews e al., 2014). In his sense, Cou neya e al. (2004) ound ha pa ien s who pe cei ed less beha io al con ol, ha is, hey el less capable o ca ying ou ac i i y, showed less adhe ence o physical ac i i y. Using he ecological model o heal h beha io as he concep ual e e ence amewo k, Lynch e al. (2010) ound ha disease-speci ic ba ie s ( a igue, no eeling well enough o be physically ac i e, dia hea, and incon inence) and pe sonal a ibu es ( ea o inju y, lack o enjoymen and in e es , and being seden a y) we e he g ea es ba ie s bo h a i e and a wel e mon hs a e diagnosis, ollowed by social en i onmen (lack o ime, no ha ing he suppo o amily, iends, and doc o ) and physical en i onmen (lack o access o acili ies, he cen e pe cei ed as unsa e and una ac i e). All o hese ba ie s we e nega i ely ela ed o pa icipa ion in physical ac i i y, excep o he disease-speci ic ba ie s. Con a y o expec a ions, pa icipan s who showed a highe le el o physical ac i i y wel e mon hs a e diagnosis also had a g ea e numbe o in ensi y o disease-speci ic ba ie s. Pe haps he symp oms and side e ec s o he disease and ea men had dec eased in gene al in his popula ion, bu hey we e mo e e iden among hose who submi ed hei body o a g ea e physical bu den by exe cising. Las ly, Peddle e al. (2008) analyzed he ac o s ha in luenced physical ac i i y pa icipa ion in hese pa ien s om sel -de e mina ion heo y. The esul s showed ha pe cei ed au onomy suppo in close people was posi i ely linked o sa is ac ion o he needs o au onomy, compe ence, and ela edness, and wi h iden i ied egula ion (a kind o mo i a ion cha ac e ized by aluing he bene i s o an ac i i y). Rela edness posi i ely p edic ed iden i ied egula ion and in ojec ed egula ion (a kind o mo i a ion cha ac e ized by a eeling o guil ), au onomy posi i ely p edic ed in ojec ed egula ion, and pe cei ed compe ence posi i ely p edic ed iden i ied egula ion. Bo h iden i ied egula ion and in ojec ed egula ion posi i ely p edic ed physical ac i i y. DISCUSSION AND CONCLUSIONS The aim o his s udy was o p o ide a global iew o he ac o s ha acili a e o hinde he physical ac i i y pa icipa ion in pa ien s wi h colo ec al cance by means o a sys ema ic e iew o he li e a u e. This is he i s sys ema ic e iew ha speci ically analyzes hese ac o s in colo ec al cance . F om all he in o ma ion collec ed in his e iew, we eached Physical ac i i y in pa ien s wi h colo ec al cance  ©Psy,Soc,&Educ,2017,Vol.9(2)  218 a ious conclusions ha will allow us o es ablish ecommenda ions o he p omo ion o physical ac i i y in his popula ion. Fi s , among he sociodemog aphic ac o s, he ollowing a o pa icipa ion in physical ac i i y in pa ien s wi h colo ec al cance : being male, whi e, younge , highe educa ional le el and highe economic s a us, ha ing a job ha does no in ol e a e y ex ensi e wo k schedule, ha ing less occupa ional expe ience, o being e i ed. Howe e , some con adic o y esul s eme ge when analyzing he in luence o ma i al s a us and pe sonal ela ionships on physical ac i i y. Speed-And ews e al. (2012) ound ha being single is ela ed o doing mo e physical ac i i y, whe eas an Pu en e al. (2016) ound ha ha ing a couple ela ionship a o s he pa icipa ion in mode a e and igo ous physical ac i i y. I is ue ha conjugal obliga ions can cause people o ha e less ime o do physical ac i i y, bu he pa ne 's suppo o ca y ou physical ac i i y du ing he disease seems essen ial (Mackenzie, 2015). Wi h ega d o heal h ac o s non-speci ic o he disease, we can conclude ha obese pa ien s pe o m less o al physical ac i i y, while pa ien s wi h lowe body mass index pe o m mo e mode a e and igo ous physical ac i i y. In addi ion, pa ien s who a e o e weigh o obese pe cei e su gical complica ions as ba ie s o exe cise o a g ea e ex en . Among he ac o s associa ed wi h psychological well-being, pa ien s wi h mo e s ess, anxie y, and dep ession pe o m less physical ac i i y whe eas hose who ha e be e quali y o li e and physical unc ioning pa icipa e mo e. Rega ding disease-speci ic heal h ac o s, pa ien s who a e no ecei ing adju an ea men , ha e ewe como bidi ies, and pe cei e be e quali y o li e pe o m mo e physical ac i i y. Du ing ea men , pa ien s pe cei e mo e ba ie s o exe cise ela ed o he side e ec s, such as a igue, dia hea, o skin i i a ion (Mo ielli e al., 2016). Al hough in gene al, ecei ing adju an ea men hinde s physical ac i i y pa icipa ion, one s udy (Bu a e al., 2012) ound ha chemo he apy was a p edic o o mode a e and igo ous physical ac i i y. The au ho s o his s udy y o explain his esul a guing ha he pa ien s who ecei ed chemo he apy we e he heal hies , he younges , and wi h ewe como bidi ies, and pe haps hey also ecei ed mo e ad ice abou physical ac i i y o alle ia e he side e ec s o chemo he apy. Conside ing he in luence o p io expe ience and p e e ences on physical ac i i y, we ind ha he pa ien s who exe cised he mos we e hose who pe o med physical ac i i y be o e diagnosis (McGowan, Speed-And ews, Blancha d e al., 2013). Thus, lack o ime was only a d awback o hose pa ien s who did no exe cise be o e diagnosis. Mo eo e , mos o he pa ien s el capable o doing physical ac i i y, hey p e e ed o ecei e in o ma ion abou physical ac i i y a e diagnosis h ough he pe sonal ad ice o a i ness expe , and p e e ed o pa icipa e in g oup-based physical ac i i y p og ams. Ne e heless, i should be highligh ed ha pa ien s wi h a s oma showed less p e e ence o g oup pa icipa ion in a i ness cen e . Ha ing access o acili ies was also a ele an ac o o physical ac i i y pa icipa ion (Speed And ews e al., 2014), and walking was he a o i e physical ac i i y bo h in summe and in win e (McGowan, Speed-And ews, Blancha d e al., 2013). This esul could be due o he ac ha walking is a simple and accessible ac i i y, i does no imply any cos and does no equi e Physical ac i i y in pa ien s wi h colo ec al cance ©Psy,Soc,&Educ,2017,Vol.9(2)  219 much knowledge abou me hods o physical aining. Howe e , some ac i i ies could be mo e ecommendable o achie e g ea e le els o in ensi y ha ansla e in o g ea e bene i s. As poin ed ou in he li e a u e, physical ac i i y dec eases du ing and a e ea men in spi e o he ac ha 150 minu es pe week o mode a e ac i i y, o 75 minu es o igo ous ac i i y, o an equi alen combina ion a e ecommended (Rock e al., 2012; Schmi z e al., 2010). In his ega d, i is likely ha pa ien s do no know wha o he ac i i ies hey can ca y ou , and speci ic p og ams o his ype o pa ien s a e p obably no p o ided in i ness cen e s. Pa ien s we e less seden a y om eigh in he mo ning un il h ee in he a e noon and mo e seden a y om six in he a e noon, eaching highe le els o igo ous physical ac i i y om ou o en in he a e noon (Lynch e al., 2016). Lea ning mo e abou he a iabili y o physical ac i i y pa e ns a di e en momen s o he day may be help ul o conside mo e app op ia e s a egies o p omo e physical ac i i y. In he ollowing sec ion, we p opose some ecommenda ions om his e idence. Las ly, we will discuss he mo i a ional ac o s ela ed o physical ac i i y beha io in hese pa ien s. Acco ding o he heo y o planned beha io , he a i ude owa ds exe cise was he only a iable ha was ela ed o he in en ion o exe cise, which in u n, was linked o pe o ming mo e pos -su ge y physical ac i i y (Cou neya e al., 1999b). Wi h ega d o belie s (Speed-And ews e al., 2014), hinking ha physical ac i i y would imp o e one's physical condi ion, ene gy le el, and well-being was associa ed wi h pe o ming mo e physical ac i i y. In addi ion, he pa ien s hough ha physical ac i i y should be suppo ed by ela i es, iends, and doc o s. Las ly, medical o heal h p oblems, pain, and elapse and e u n o ea men , we e he mos equen ly epo ed con ol belie s ha hinde ed physical ac i i y pa icipa ion. Based on sel -de e mina ion heo y, one s udy showed ha au onomy suppo , sa is ac ion o he h ee basic psychological needs (au onomy, compe ence and ela edness), and iden i ied and in ojec ed egula ions we e impo an a iables o physical ac i i y pa icipa ion in pa ien s wi h colo ec al cance (Peddle e al., 2008). The esul s o his e iew ha e allowed us o so and classi y all he exis ing in o ma ion on his opic o da e. When designing physical ac i i y p og ams o colo ec al cance pa ien s, sociodemog aphic ea u es, heal h ac o s, p io expe ience and p e e ences, as well as ce ain mo i a ional ac o s should all be alued. The di e en conclusions eached should be aken in o accoun o he de elopmen o physical ac i i y in his popula ion, conside ing he impo an bene i s ha can be achie ed. RECOMMENDATIONS D awing om he esul s ob ained in his e iew, we p esen he ollowing ecommenda ions o p omo e physical ac i i y in pa ien s wi h colo ec al cance : 1) The exis ence o a less ac i e p o ile in hese pa ien s, oge he wi h he physical and psychological side e ec s caused bo h by he disease i sel and by he ea men , e eals he need o c ea e speci ic p og ams o physical ac i i y a ge ing his popula ion, which con empla e hei pe sonal ea u es. Special a en ion should be paid o he p omo ion o physical ac i i y among olde pa ien s, women, and pa ien s Physical ac i i y in pa ien s wi h colo ec al cance  ©Psy,Soc,&Educ,2017,Vol.9(2)  220 wi h lowe socioeconomic s a us and educa ional le el, because hese sec o s o he popula ion a e less in e es ed in doing physical ac i i y. 2) The p og ams should inco po a e mo i a ional s a egies o os e a posi i e clima e du ing he sessions o physical ac i i y, ensu ing ha he pa icipan s eel espec ed and alued. Social en i onmen s should no only be inclusi e bu also he s uc u e o he exe cise acili ies should a o he inclusion o pa ien s wi h colo ec al cance . Fo example, he inco po a ion o showe s and changing ooms ha comply wi h he p i acy o pa ien s wi h a s oma, who may su e om a p oblem ela ed o body image, would be desi able. 3) I would be in e es ing o in o m he pa ien s abou he bene i s o physical ac i i y o hei disease, conduc ing semina s in he heal h cen e s. These semina s could include es imonials om pa ien s who ha e al eady o e come he disease and who ca ied ou physical ac i i y du ing i s cou se. This could imp o e pa ien s' a i ude owa ds physical ac i i y and hei in en ion o exe cise. 4) P o essionals om he spo sciences should be inco po a ed in o he mul idisciplina y medical eam so ha hey could ad ise pa ien s, ecommend he bes physical ac i i y o each indi idual, and design indi idualized aining p og ams. The compe ence o he p o essionals in cha ge o he di ec ion o physical ac i i y p og ams is essen ial because colo ec al cance pa ien s a e in a delica e heal h si ua ion and need o be assu ed ha hei exe cise will be ca ied ou in condi ions o sa e y o ob ain he mos bene i s and ake as ew isks as possible. 5) I u u e s udies wi h accele ome e s con i m ha pa ien s wi h colo ec al pa icipa e less in physical ac i i y in he mo ning, p og ams o ac i e es du ing wo king hou s could be designed, and ac i e commu ing o e e yday ips could be os e ed. Likewise, i would be in e es ing o de elop physical ac i i y p og ams in he a e noon ime slo s which pa ien s usually dedica e o leisu e. 6) G oup ac i i ies o p omo e social ela ions among pa ien s who a e engaged in exe cise p og ams could be designed, and also adap ing he aining loads o each pe son and o e ing au onomy. Thus, mo e sel -de e mined mo i a ion would be achie ed and, he eby, mo e in ol emen and adhe ence o physical ac i i y. To achie e hese goals, i would also be necessa y o p omo e pa ien s' pe cep ion o compe ence, so hey will eel capable o pa icipa e in physical ac i i y p og ams. 7) Family, iends, heal h p o essionals, and o he pa ien s/pee s should collabo a e in he p omo ion o an ac i e and heal hy li es yle in people su e ing om colo ec al cance . Social suppo can be essen ial o hese pa ien s o acqui e habi s o physical ac i i y ha can con ibu e o alle ia ing he symp oms o hei disease and o subs an ially imp o ing hei quali y o li e. LIMITATIONS OF THE LITERATURE AND FUTURE RESEARCH DIRECTIONS In spi e o he esul s ound in his e iew, we also iden i ied impo an gaps in he li e a u e ha we shall de ail in he ollowing pa ag aphs. Fi s , i should be no ed ha , ou o all he e iewed a icles, only 5 used an expe imen al design. The e is s ill a lack o knowledge abou he ype, equency, du a ion, and in ensi y o physical ac i i y ha a e necessa y o op imize Physical ac i i y in pa ien s wi h colo ec al cance ©Psy,Soc,&Educ,2017,Vol.9(2)  221 he physical and psychosocial bene i s and educe he isks in pa ien s wi h colo ec al cance a di e en phases o ea men and as a unc ion o he ypes o ea men . Inc easing his knowledge is essen ial o imp o e he he apeu ic e ec s o exe cise and o p omo e physical ac i i y pa icipa ion in hese pa ien s. In addi ion, mo e s udies a e needed o implemen and analyze he e ec o s a egies o mo i a e hese pa ien s o pa icipa e in physical ac i i y. I is also necessa y o highligh ha only one s udy collec ed in o ma ion by means o quali a i e echniques. The e is a lack o quali a i e s udies ha analyze in dep h he easons ha lead pa ien s wi h colo ec al cance o pa icipa e in physical ac i i y, as well as he ba ie s hey ind. I would be in e es ing o combine expe imen al designs wi h quali a i e echniques o da a collec ion, a emp ing o con i m he psychosocial e ec s o speci ic g oup- based physical ac i i y p og ams o his popula ion, as well as o iden i y possible p oblems ha may a ise du ing he cou se o such p og ams. The eby, we would ob ain mo e i al and comp ehensi e knowledge o design and implemen app op ia e p og ams o physical ac i i y o hese pa ien s. Ano he o he limi a ions ound in his e iew is ha mos o he s udies do no use a heo e ical amewo k o e e ence. O he 23 a icles ha make up his sys ema ic e iew, only 5 s udies used he heo y o planned beha io , 2 applied he ecological model o heal h beha io , and only 1 s udy is based on sel -de e mina ion heo y o analyze he ac o s ha in luence adhe ence o physical ac i i y in pa ien s wi h colo ec al cance . Howe e , as some au ho s indica e (Biddle e al., 2012), i is necessa y o apply heo e ical amewo ks ha guide he s udies and allow us o unde s and he in o ma ion accu a ely and in a s uc u ed way. Acco dingly, i is s iking ha only one s udy applied sel -de e mina ion heo y wi h colo ec al cance pa ien s, aking in o accoun ha his heo y has p o en o be one o he mos ele an o s udy beha io in heal h con ex s (Ng e al., 2012). Besides, mos o he s udies measu e physical ac i i y by means o ques ionnai es, excep o one s udy ha inco po a ed a mo e objec i e measu e using accele ome y. New s udies a e necessa y o analyze he le els o physical ac i i y in pa ien s wi h colo ec al cance objec i ely, in o de o de e mine hei ela ionships wi h di e en ac o s ha may inc ease o dec ease hem. The inc easingly ad anced de elopmen o wea able de ices o acking physical ac i i y could acili a e his ask acco dingly. Las ly, ou o he 23 e iewed a icles, 11 s udies analyzed he ac o s associa ed wi h he pe o mance o physical ac i i y du ing he complemen a y ea men o su ge y, ano he 9 we e ca ied ou a e inishing he ea men o only a mino i y o pa ien s was in ea men , and 3 s udies did no speci y he ime o ea men . F om ou iewpoin , he di e ences be ween he ac o s ha p omo e o hinde physical ac i i y pa icipa ion du ing and a e he complemen a y ea men o su ge y emain unclea . A g ea e analysis o hese ac o s h oughou he en i e p ocess o he cance is necessa y (Milne, Wallman, Guil oyle, Go don, & Cou neya, 2008), e en analyzing he ba ie s ha may appea du ing a “chemo he apy week” compa ed o a week o es om chemo he apy, o know mo e speci ically how he side e ec s o he ea men a ec he le els o physical ac i i y. 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