Levels of Physical Activity and Sedentary Lifestyle in Patients With Hematological Cancer Treated With Monoclonal Antibodies as a Monotherapy or Combination Therapy (Immunochemotherapy): A Comparative Study With Healthy Individuals

Introduction

There is a growing trend in cancer incidence worldwide, including hematological cancers, which account for 7% of all malignant cancers. Such cancers accounted for 1.32 million cases in 2022, of which 636 000 were lymphomas, 497 000 were leukemias, and 188 000 were myelomas [1]. In Poland, data from the National Cancer Registry show that the incidence rates for blood cancers do not differ significantly from those in other European countries. A marked increase in the incidence of blood and lymphatic system cancers is common to the populations of all developed countries due to changes in demographic structure [2]

At the same time, recent years have seen dynamic progress in understanding the pathogenesis of blood diseases, which has led to many changes in their treatment. The rapid development of targeted therapies and immunotherapy, both cellular and humoral, has increased the survival rate of patients with hematological cancers [3]. Thus, the percentage of cancer survivors is increasing [4].

Consequently, there is an increasing need to introduce rehabilitation from the moment of diagnosis, both during and after treatment. Regular physical activity is essential for preventing functional decline, preserving muscle mass, and reducing the severity of cancer-related fatigue. The most common adverse effects of cancer treatment are anemia, thrombocytopenia, neutropenia, peripheral neuropathy, fatigue, and reduced physical performance. At the same time, these symptoms may potentially be reduced through appropriately tailored individual exercise programs. The toxicity profile of the drugs used (monoclonal antibodies administered as monotherapy or combination therapy as immunochemotherapy) may limit a patient’s ability to engage in physical activity, leading to further functional decline. To avoid this vicious circle, patients with hematological cancers should be encouraged to undertake physical activity.

Physical activity is a complementary, non-pharmacological method of alleviating symptoms and improving mental and physical health [5,6]. Due to the proven effects of physical activity on mental functioning and quality of life, it is necessary to continuously raise the awareness among patients with hematological cancers in this area [7]. Guidance on physical activity should become an integral part of the treatment plan for these patients [6].

According to World Health Organization (WHO) and American Cancer Society guidelines, adults, including patients with cancer, should engage in at least 150 to 300 minutes of moderate physical activity or 75 to 150 minutes of intense physical activity per week, as well as limit the time spent in a sitting position. In clinical practice, however, a significant proportion of patients with hematological cancers do not achieve the recommended level of activity, which may adversely affect the course of treatment, quality of life, and risk of complications, especially in older adults, who experience a decline in physical activity with age [8].

Büntzel et al demonstrated a decrease in physical activity in patients with cancer from 71% before onset to 50% during treatment and 40% after anticancer treatment [9]. In turn, Sweegers et al pointed to the preference for a sedentary lifestyle among oncology patients [10].

Therefore, in this study, we aimed to assess the level of physical activity and sedentary lifestyle of patients with hematological cancers treated with monoclonal antibodies as a monotherapy or combination therapy (immunochemotherapy), compared with that of healthy individuals.

Material and Methods

PARTICIPANTS AND RECRUITMENT:

A cross-sectional comparative study was conducted with 292 participants, including 155 individuals in the study group consisting of patients from the Hematology and Transplantation Center of the Lower Silesian Center for Oncology, Pulmonology, and Hematology, in Wrocław. The reference group consisted of 137 healthy individuals with no history of cancer or comorbidities. Both groups were divided according to age, following WHO recommendations on physical activity, into groups of adults aged 18 to 64 years and older adults aged 65 years and above.

In addition, the study group was divided into 4 subgroups according to diagnosis of chronic lymphocytic leukemia (n=27), multiple myeloma (n=34), Hodgkin lymphoma (n=34), and follicular lymphoma (n=60).

The inclusion criteria for the study group were (1) age of 18 years or older, (2) a diagnosis of hematological cancer based on current diagnostic standards, (3) treatment with immunochemotherapy or, in the case of chronic lymphocytic leukemia, anti-CD-20 antibodies in combination with B-cell receptor inhibitors and B-cell lymphoma 2 inhibitors (Venetoclax), and (4) clinical status allowing completion of the questionnaires and written consent to participate in the study. The criteria for inclusion in the reference group were (1) age of 18 years or older, (2) being healthy (no comorbidities), (3) never having been treated for a malignancy or other chronic diseases, and (4) not taking regular medication.

The exclusion criteria were intellectual or physical disability and lack of consent to participate in the study.

RESEARCH METHODS AND THE INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE:

The International Physical Activity Questionnaire (IPAQ) assessed the level of physical activity and sedentary lifestyle. The short version of the IPAQ was used in this study. This version was selected due to the specific characteristics of the study group. The use of the short IPAQ reduces respondent burden and shortens the time required to complete the questionnaire, which may improve the completeness of the collected data and minimize the risk of errors resulting from participant fatigue. The IPAQ is a self-assessment tool for physical activity. All patients completed the questionnaire independently after receiving detailed instructions from the medical staff. The IPAQ consists of 7 questions. The questions concern physical activity undertaken in the last 7 days, considering activities related to important areas of human life, such as professional work, household and garden activities, moving from place to place, and leisure and sports in free time. In addition, the time spent sitting is determined. Physical activity includes activities that last at least 10 minutes without interruption.

The types of activity measured are: walking, moderate activity, and intense activity. Individual types of physical activity are expressed in metabolic equivalent of task (MET) units (min/week). Respondents are classified into 1 of 3 activity categories: insufficient (below 600 MET), sufficient (600–1500 or 600–3000 MET), or high (above 1500 or 3000 MET) [11].

For this questionnaire, the standardized Cronbach alpha test showed values from 0.63 to 0.85 [12]. The IPAQ has demonstrated validity and reliability across diverse contexts, including the Polish population [13].

ETHICS:

All participants provided written informed consent to participate in the study. The Senate Research Ethics Committee, Wroclaw University of Health and Sport Sciences, approved the study (consent number: 28/2023; date of approval: January 12, 2024).

STATISTICAL ANALYSIS:

The Shapiro-Wilk test assessed the normality of the data distribution. Due to the non-normal distribution of the analyzed characteristics, the median was used as a measure of central tendency and the interquartile range (IQR) as a measure of dispersion. Analysis of differences between the groups was conducted using the Mann-Whitney U test or Kruskal-Wallis analysis of variance (ANOVA) with the Dunn’s post hoc test with Bonferroni-Holm correction. The effect size for the Mann-Whitney U test and Kruskal-Wallis ANOVA was estimated using the Eta squared (η2) value transformed to the Cohen’s d coefficient [14]. The significance level was set at P<0.05. All analyses used Statistica 13.1 software and an online effect size calculator: https://www.psychometrica.de/effect_size.html (accessed on July 15, 2025).

The sample size was determined using G*Power 3.1.9.2 software (G*Power, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany). It was assumed that the study group differed from the reference group. The test power was calculated a priori for independent samples, assuming a significance level of α=0.05, test power (1-β)=0.95, and an average effect size (Cohen’s d=0.42). The analysis indicated that the minimum total sample size should be 260 (130 participants in each group). The sample size was increased to compensate for possible participant dropouts, assuming a 12% dropout rate, and ultimately 292 participants were recruited.

Results

BASIC SOCIODEMOGRAPHIC DATA:

The study groups did not differ significantly in terms of age, sex, education, marital status, and place of residence. However, a significant difference was found between the study group and reference group, regardless of age group (adults and older adults), in terms of employment. Furthermore, a lower body mass index (BMI) was found in the older adult group than in the reference group. Table 1 presents the sociodemographic characteristics of the groups.

GENERAL PHYSICAL ACTIVITY LEVEL:

The IPAQ questionnaire results indicated a lack of moderate and intense physical activity among patients with hematological cancers, regardless of age group. Although these patients showed significantly lower activity levels compared with healthy individuals, adherence to WHO guidelines was also low among the healthy group (Tables 2, 3).

PHYSICAL ACTIVITY LEVEL BY AGE GROUP, ACCORDING TO WHO RECOMMENDATIONS ON PHYSICAL ACTIVITY:

For the younger adult group of the study and reference groups, significant differences were obtained for intense activities expressed in minutes per week (Me [IQR], 0.00 [60.00] vs 60.00 [180.00]; P<0.0001) and METs (Me [IQR], 0.00 [480.00] vs 480.00 [1440]; P<0.0001), and for moderate activities expressed in minutes per week (Me [IQR], 80.00 [180.00] vs 135.00 [300.00]; P=0.0018) and METs (Me [IQR], 320.00 [720.00] vs 540.00 [1200.00]; P=0.0013). The study group also differed significantly in terms of sitting time (Me [IQR], 1200.00 [900.00] vs 360.00 [360.00]; P<0.0001) and overall IPAQ score (METs) (Me [IQR], 1235.00 [2550.00] vs 3186.00 [3711.00]; P<0.0001) (Table 2).

In the older adult group of the study and reference groups, significant differences in results were observed for moderate activities expressed in minutes per week (Me [IQR], 30.00 [180.00] vs 100.00 [200.00]; P=0.03) and METs (Me [IQR], 0.00 [720.00] vs 400.00 [800.00]; P=0.01). Significant differences were also observed in the performance of intense activities expressed in METs (Me [IQR], 0.00 [240.00] vs 0.00 [960.00]; P=0.04), as well as in sitting time (Me [IQR], 900.00 [600.00] vs 300.00 [300.00]; P<0.0001) (Table 3).

PHYSICAL ACTIVITY BASED ON CLINICAL DIAGNOSIS:

Regardless of age group, significant differences (P<0.05) were found in the duration of sitting when considering diagnosis (chronic lymphocytic leukemia, multiple myeloma, Hodgkin lymphoma, or follicular lymphoma) between the study and reference groups.

In the younger adult groups, patients diagnosed with myeloma exhibited the longest sitting times compared with the reference group (Me [IQR], 1650.00 [600.00] vs 360.00 [360.00]; P<0.0001). In the older adult groups, the longest sitting times were observed in patients diagnosed with myeloma (Me [IQR], 1200.00 [900.00] vs 300.00 [300.00]; P=0.0004) and Hodgkin lymphoma (Me [IQR], 1200.00 [300.00] vs 300.00 [300.00]; P=0.03).

Among younger adults, patients with myeloma also had significantly lower levels of intense activities compared with the reference group, both in minutes per week (Me [IQR], 0.00 [0.00] vs 60.00 [180.00]; P=0.01) and in METs (Me [IQR], 0.00 [0.00] vs 480.00 [1440.00]; P=0.01), as well as in overall IPAQ scores (Me [IQR], 900.00 [1035.75] vs 3186.00 [3711.00]; P=0.01).

In the same younger adult group, patients diagnosed with Hodgkin lymphoma demonstrated significantly lower moderate activity compared with the reference group, both in minutes per week (Me [IQR], 10.00 [90.00] vs 135.00 [300.00]; P=0.002) and in METs (Me [IQR], 40.00 [360.00] vs 540.00 [1200.00]; P=0.02).

Tables 4–6 provide detailed results of the levels of physical activity and sedentary lifestyle based on clinical diagnosis.

Discussion

STRENGTHS AND LIMITATIONS:

The main limitation of this study is that it was based solely on a subjective assessment of physical activity using the IPAQ questionnaire. The use of a single subjective measure to assess physical activity limits the depth of the findings. The results obtained may be either underestimated or overestimated. However, the IPAQ is an international, standardized questionnaire for assessing levels of physical activity and sedentary behavior and is used in population and clinical studies.

Another limitation of the present study is the lack of precise information on cancer stage and performance status. However, the duration of disease across individual cases was similar, all patients were treated on an outpatient basis, and none had physical limitations that could affect their ability to engage in physical activity.

FUTURE RESEARCH DIRECTIONS:

The results of the IPAQ questionnaire could be strengthened by providing additional details about the types of physical activity most commonly undertaken by patients with hematological cancers. This data could help develop educational programs promoting an active lifestyle for this group of patients. Furthermore, future research should focus on the implementation of objective tools, such as accelerometry, for assessing physical activity levels and be conducted at various stages of treatment in order to determine the possibilities for physical activity throughout the treatment process. This could strengthen the obtained results.

Conclusions

The conclusions of this study are as follows. First, patients with hematological cancers treated with monoclonal antibodies as a monotherapy or combination therapy (immunochemotherapy) show, regardless of age, lower levels of physical activity and longer sitting times than do healthy individuals, indicating the need for education and promotion of physical activity in this group of patients. Second, regardless of age, differences in employment status were observed. This result may be related to psychophysical stamina and indirectly affect the level of physical activity undertaken. Third, a lower BMI was observed in the older adult group, which may indicate cachexia, as cancer-related wasting is directly related to the level of physical activity undertaken. Finally, further longitudinal studies using objective methods of physical activity monitoring are needed to better understand these relationships.