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Anxieties, age and motivation
influence physical activity in
patients with myeloproliferative
neoplasms - a multicenter
survey from the East German
study group for hematology
and oncology (OSHO #97)
Sabine Felser
1
*, Julia Rogahn
1
, Philipp le Coutre
2
,
Haifa Kathrin Al-Ali
3
, Susann Schulze
3,4
, Lars-Olof Muegge
5
,
Julia Gruen
1
, Jan Geissler
6
, Veronika Kraze-Kliebhahn
7
and Christian Junghanss
1
1
Department of Internal Medicine, Clinic III –Hematology, Oncology and Palliative Care, Rostock
University Medical Center, Rostock, Germany,
2
Department of Hematology, Oncology, and Cancer
Immunology, Charite
´Campus Virchow-Klinikum, Charité, Universitätsmedizin Berlin,
Berlin, Germany,
3
Krukenberg Cancer Center Halle, University Hospital Halle, Halle (Saale),
Halle, Germany,
4
Department of Internal Medicine, Medical Clinic II, Carl-von-Basedow-
Klinikum, Merseburg, Germany,
5
Department of Internal Medicine III, Heinrich Braun Hospital,
Zwickau, Germany,
6
LeukaNET/Leukemia Online e.V., Riemerling, Germany,
7
MPN-Netzwerk e. V.,
Bonn, Germany
Background: Physical activity (PA) is a non-pharmacological approach to
alleviate symptom burden and improve health-related quality of life (HrQoL)
in cancer patients (pts). Whether pts with myeloproliferative neoplasms (MPN)
PA behavior changes due to symptom burden and/or knowledge of the
putative beneficial effects of PA has not yet been investigated.
Methods: We performed a large questionnaire study in MPN pts. Self-reported
PA behavior and potential influencing factors of 634 MPN pts were analyzed.
Questionnaires were used to assess demographics, anxiety, severity of
symptoms, HrQoL, current level of everyday and sports activities, and the
level of information regarding the importance/possibilities of PA. According to
their PA, the pts were assigned to the three groups: “inactive”,“non-targeted
active”, and “sporty active”and compared with each other.
Results: Key findings are that in 73% of the pts, the disease had an impact on PA,
with 30% of pts reducing their PA. The prevalence of anxieties (e.g., occurrence
of thrombosis and bleeding) regarding PA was 45%. Sporty active pts had a
lower symptom burden and better HrQoL (p≤0.001) compared to the other
groups. Inactive pts were significantly older and had a higher body mass index
than sporty active pts. Inactive and non-targeted active pts felt less informed
about the importance/possibilities of PA (p= 0.002).
Frontiers in Oncology frontiersin.org01
OPEN ACCESS
EDITED BY
Massimo Breccia,
Sapienza University of Rome, Italy
REVIEWED BY
Silvia Riva,
St Mary’s University, United Kingdom
Zefeng Xu,
Chinese Academy of Medical Sciences
and Peking Union Medical College,
China
*CORRESPONDENCE
Sabine Felser
sabine.felser@med.uni-rostock.de
SPECIALTY SECTION
This article was submitted to
Hematologic Malignancies,
a section of the journal
Frontiers in Oncology
RECEIVED 29 September 2022
ACCEPTED 12 December 2022
PUBLISHED 04 January 2023
CITATION
Felser S, Rogahn J, le Coutre P, Al-
Ali HK, Schulze S, Muegge L-O,
Gruen J, Geissler J, Kraze-Kliebhahn V
and Junghanss C (2023) Anxieties,
age and motivation influence
physical activity in patients with
myeloproliferative neoplasms - a
multicenter survey from the East
German study group for hematology
and oncology (OSHO #97).
Front. Oncol. 12:1056786.
doi: 10.3389/fonc.2022.1056786
COPYRIGHT
© 2023 Felser, Rogahn, le Coutre, Al-Ali,
Schulze,Muegge,Gruen,Geissler,
Kraze-Kliebhahn and Junghanss. This is
an open-access article distributed under
the terms of the Creative Commons
Attribution License (CC BY). The use,
distribution or reproduction in other
forums is permitted, provided the
original author(s) and the copyright
owner(s) are credited and that the
original publication in this journal is
cited, in accordance with accepted
academic practice. No use,
distribution or reproduction is
permitted which does not comply
with these terms.
TYPE Original Research
PUBLISHED 04 January 2023
DOI 10.3389/fonc.2022.1056786
Conclusion: Our results suggest that especially older and non-sporty
MPN pts could benefit from motivational as well as disease-specificPA
information. This study was registered at the German Registry of Clinical
Trials, DRKS00023698.
KEYWORDS
anxieties, education, fatigue, fears, health-related quality of life (HrQoL),
myeloproliferative neoplasms (MPN), physical activity, sports
1 Introduction
Patients (pts) with myeloproliferative neoplasms (MPN) suffer
from a variety of disease- and therapy-related symptom burden. In
addition to fatigue, the most common symptoms include
concentration problems, bone pain, headache, dizziness,
microcirculatory symptoms, itching, night sweet, depression, and
anxiety (1–4). In advanced disease, splenomegaly is common and
often associated with abdominal discomfort, loss of appetite, and
leads to weight loss in about one-fifth of pts (1,5). All of these
symptoms have implications on physical performance, emotional
well-being, and health-related quality of life (HrQoL), and lead to
work productivity impairments (1,6,7). Thanks to advances in
diagnostics and therapy, many MPN pts have an almost normal life
expectancy (8,9). Of note, myelofibrosis (MF) -primary or
secondary- is often associated with a more severe disease course
and decreased overall survival (10). Pts with chronic myeloid
leukemia (CML) benefit in regards to life expectancy from the
effectiveness of tyrosinkinase inhibitors (TKI). Due to the
predominantly chronic courses of the diseases, MPN pts suffer
from symptoms throughout their lives. Thus, HrQoL is increasingly
becoming a focus of MPN treatment.
Based on the evidence regarding the effects of physical activity
(PA) on functionality, symptom burden, and HrQoL in pts with
solid tumors, acute leukemia, lymphomas, and myelomas (11,12), it
is reasonable to assume that PA may be an effective non-
pharmacological approach to reduce symptom burden and
improve HrQoL in MPN pts (13). Whether MPN pts’PA
behavior changes due to symptom burden and/or knowledge of
the putative beneficial effects of PA has not yet been investigated.
Similarly, it is unclear whether the consequences of impaired
hematopoieticsystemfunctionhaveanimpactonPA.MPNpts
often have an increased risk of thrombosis and infection, an
increased bleeding tendency and/or anemia, accompanied by a
reduced performance capacity (3,4,9). Itching and skin reactions
could also have an impact on PA.
To support MPN pts in maintaining or implementing a
physically active lifestyle in the long term, targeted information
is warranted. The present study investigated which factors show
an association with PA in MPN pts. The present study
investigated (I) whether and how PA behavior changes due to
a MPN disease, (II) whether anxiety of certain events such as
thrombosis, bleeding, and skin reactions have an influence on
PA, (III) how physically inactive MPN pts differ from active pts,
and (IV) whether MPN pts have knowledge of the importance
and possibilities of PA.
2 Materials and methods
The study was designed as a multicenter cross-sectional
study. It was approved by the Ethics Committee of the
University of Rostock (A2020-0274) and registered with the
German Registry of Clinical Trials: DRKS00023698. Pts ≥18
years with any type of MPN (14) could participate in the survey.
Eligible pts of 12 institutions in the East German Study Group
Hematology and Oncology (OSHO, Online Supplementary S1)
were asked to participate and fill in a hard copy questionnaire
(enrollment January 2021 to September 2021). From April 2021
to September 2021, the study was amended by an online version
of the survey consisting of the same set of questions. Participants
included pts of the LeukaNET/Leukemia-Online pts network as
well as the German, Austrian, and Swiss MPN pts network.
Questionnaire
General information. The following general characteristics
were collected: gender, age, education level, family status,
profession, height, and weight. The Body Mass Index (BMI)
was calculated.
Details of the disease. MPN subtype, year of diagnosis, disease-
specific therapies (e.g. TKI, januskinase (JAK) inhibitors, cytostatics
(e.g. hydroxyurea, anagrelid, busulfan, clardibrin), inteferon, and
other therapies (e.g., anticoagulation, phlebotomy) were inquired.
Physical activity. Questions asked for whether and how the
PA had changed in everyday life and during sports since the
diagnosis of the MPN, and whether they are afraid of certain
Felser et al. 10.3389/fonc.2022.1056786
Frontiers in Oncology frontiersin.org02
events (e.g., bleeding). Everyday activity was measured with the
Godin-Shepard Leisure-Time Physical Activity Questionnaire
(GSLTPAQ) and was classified into three categories:
“insufficiently active”,“moderately active”,and“active”(15,
16). Additionally, the five stages of the transtheoretical model
of behavioral change (SOC) were used to determine the
motivation to participate regularly in sports (17,18). In the
stages of precontemplation, contemplation, and preparation, pts
are not regularly active in sports. In the stages of action and
maintenance, pts are active for at least 20 minutes on at least 3
days per week. The questionnaires (GSLTPAQ, SOC) are
provided in the Online Supplementary S2.
HrQoL and symptoms. HrQoL was assessed by a visual
analogue scale (VAS) ranging from 0 (very poor) to 100 (very
good). Symptoms were assessed using single items of the MPN
Symptom Assessment Form (MPN-SAF) (19), supplemented by
other typical symptoms of CML, ranging from 0 (absent) to 100
(worst imaginable). Further, weight changes, potential side
effects of MPN such as skin reactions, splenomegaly, as well as
the number of falls in the last 12 months were inquired.
Information level. It was recorded whether the pts felt
sufficiently informed about the importance and possibilities of
PA and the desire for more information.
Activity groups
Pts were divided into three groups depending on their level
of everyday (GSLTPAQ) and sports activities (SOC). Group 1
“inactive”: all insufficiently active pts who do no sports at all.
Group 2 “non-target active”: all moderately and sufficiently
active pts who do no sports at all. Group 3 “sporty active”: all
moderately and sufficiently active pts who do sports regularly.
Statistical analysis
Continuous data are reported as means ± standard
deviation, and categorical variables as counts and percentages.
Mean differences for continuous variables were tested using
Mann-Whitney U test and c
2
-test for categorical variables. All
data were analyzed using SPSS (version 25.0, IBM, Chicago, IL,
USA). Statistical significance was assumed for p-values < 0.05.
3 Results
Sample characteristics
In total, 766 questionnaires were received, of which 315
(41%) were in hard copy and 451 (59%) online. The response
rate (handed out/received filled in) of the hard copy survey was
78%. Reasons for exclusion of questionnaires are presented in
Figure 1. The final sample cohort comprised 634 questionnaires
(63% women, mean age 57 ± 14 years). General characteristics,
including the medical history of this cohort, are presented in
Table 1. The pts were diagnosed between 1981 and 2021. The
median age of MPN onset was 50 ± 14 years.
Further demographics and current therapies at the time of the
survey are presented in Table 2. The CML pts were the youngest pts
(mean 51 ± 14 years), the polycythemia vera (PV) pts were the
oldest (mean 61 ± 12 years). Of the 183 CML pts, 171 received
FIGURE 1
Flow chart of the study. D, Germany; AUT, Austria; CH, Switzerland; MPN, myeloproliferative neoplasms. *Participating institutions are presented
in the supplement (Table S1).
Felser et al. 10.3389/fonc.2022.1056786
Frontiers in Oncology frontiersin.org03
disease-specific therapy. Of these, 158 (92%) were treated with TKI.
One hundred thirty-two of the 166 PV and 133 of the 155 essential
thrombocythemia (ET) pts received disease-specifictherapy,most
frequently with cytostatics (n = 55, 42% and n = 70, 53%,
respectively). Thirteen (10%) of PV and 36 (27%) of ET pts were
on a watch-and-wait strategy. The most common disease-specific
therapy among MF pts was treatment with a JAK-2 inhibitor, (n =
56, 52%) followed by a watch-and-wait strategy (n = 22, 20%).
Regardless of disease-specifictherapy,66(40%)PV,87(56%)ET,
and31(26%)MFptsreceivedanticoagulation. Sixty-three (38%)
PV pts underwent phlebotomy. The total cohort included seven pts
with splenectomy.
Influence of MPN disease on physical
activity and anxiety
The influence of a MPN disease on the PA of those affected is
presented in Figure 2. Most participants (n = 455, 73%) changed
their self-reported PA behavior in everyday life and/or sports.
Both, the decade of diagnosis and the type of therapy in PV/ET/
MF pts showed no significant group differences. Group
differences were only found depending on the diagnosis. The
percentage of those who changed their PA behavior was lowest
among the CML pts (65%) and highest among the MF pts (81%).
In everyday life, 177 (35%) reported being less active and 78
(15%) more active. Especially pts with MF and PV reduced their
everyday activities (47% and 40% respectively). The proportion
of pts who have been more active in everyday life since diagnosis
is highest among ET pts (23%) and lowest among MF pts (8%).
Two hundred one pts (33%) moved more consciously in
everyday life and 132 (22%) moved more carefully. The latter
finding was especially relevant in pts with MF and PV (29% and
25%, respectively). In sports, 191 (40%) of the 455 pts reduced
their training, with the proportion being lowest among ET pts at
28% and highest among MF pts at 52%. In contrast, 76 (16%)
reported exercising more since diagnosis, which was most
common for ET pts (21%). One hundred and eighty-one
(31%) were more conscious during sports and 123 (21%) were
more careful.
Thirty percent of those who moved/exercised more consciously
were more physically active. In contrast, 68% of those who were
more careful were less physically active. Pts who reported moving
less after diagnosis tended to have more anxiety about certain events
than pts who reported moving as much or more (54% vs. 31% and
33%, respectively, p≤0.001). Which events MPN pts are most
afraid of during PA are presented in Figure 3. Overall, 278 (45%)
participants reported that they were afraid of at least one event.
There were no significant group differences in the prevalence of
anxiety according to diagnosis. Anxiety about infections (52%) and
thrombosis (51%) were mentioned most frequently, followed by
bleeding (32%) and skin reactions (31%). Group differences were
found in anxiety about infections (p=0.038)andthrombosis(p≤
0.001). While CML pts had more anxiety about infections, ET and
PV pts had more anxiety about thrombotic events compared to the
other MPN subtypes. MF pts tended to have more anxiety about
splenic rupture compared to the other MPN subtypes (22% vs.8-
11%, respectively, p=0.091).
TABLE 1 Sample characteristics (n = 634).
n Values
General characteristics
Gender 633
women 398 (62.9)
men 235 (37.1)
Age [years] 632 57.1 ± 13.9
BMI [kg/m²] 627 25.8 ± 4.9
School education 609
≤10 years 265 (43.5)
> 10 years 344 (56.5)
Family status 630
single 107 (17.0)
married/living with a partner 483 (76.7)
other 40 (6.3)
Profession 624
working* 339 (54.3)
retired 239 (38.3)
other 46 (7.4)
Medical history
Year of diagnosis 586
≥2020 90 (15.4)
≥2010 and < 2020 371 (63.3)
≥2000 and < 2010 108 (18.4)
< 2000 17 (2.9)
MPN subtype 634
CML 183 (28.9)
PV 166 (26.2)
ET 155 (24.4)
MF 117 (18.5)
others 13 (2.1)
Data are presented as the number of participants (%) for categorical variables and as
mean ± standard deviation for continuous variables.
n, number of patients; BMI, Body Mass Index; CML, chronic myeloid leukemia; PV,
polycythemia vera; ET, essential thrombocythemia; MF, myelofibrosis
*42 (12.1%) patients were on sick leave at the time of the survey.
Felser et al. 10.3389/fonc.2022.1056786
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Physical activity level and motivation
for regular sports
Regarding the GSLTPAQ score, 110 (19%) of the total
cohort were categorized as insufficiently active, 109 (19%) as
moderately active, and 361 (62%) as active. The analysis of
SOC revealed that 203 (34%) pts were not action-oriented
(stage of precontemplation), 98 (16%) and 41 (7%) were in the
stages of contemplation and preparation, respectively. In total,
257 (43%) pts reported regular sports (stages of action and
maintenance). The results for the different diagnoses are
available in the Online Supplementary S3.Thereareno
significant group differences in everyday activity (GSLTPAQ)
or motivation to do regular sports (SOC) depending on
diagnosis or therapy in PV/ET/MF pts.
Activity groups
All MPN pts who reported both GSLTPAQ and SOC (n = 559)
were assigned to an activity group according to the information
provided. For 18 (3%) pts, the information provided was not
plausible. These were excluded from the subgroup analysis. The
SOC as a relation to the GSLTPAQ scores are presented in Figure 4.
Eighty-six (15%) pts were assigned to Group 1 “inactive”, 229 (41%)
to Group 2 “non-targeted active”,and226(40%)toGroup3
“sporty active”.
Demographics, HrQoL, and symptom
burden depending on the activity group
The demographics, HrQoL, symptoms, and side effects of the
MPN pts, depending on the activity group, are presented in Table 3.
Theinactiveptsweresignificantly older than those in the two active
groups (Group 2: 60 ± 16 years vs. 56 ± 13 years; p= 0.018; Group 3:
55 ± 13 years; p= 0.004), and had a higher BMI than the sporty
active group (27 ± 5 vs. 25 ± 5, p=0.013).Thesportyactivegroup
rated their HrQoL significantly higher than the other two groups
(Group 1: 73 ± 20 vs. 60 ± 23, p≤0.001vs.Group2:63±21,p≤
0.001). In addition, the sporty active group reported significantly
less fatigue, bone and muscle pain, and concentration problems (all:
p≤0.05), compared to both groups. There were no differences in
HrQoL and symptom burden between the inactive and non-
targeted active pts.
Inactive MPN pts tended to gain weight more often than the
active ones (29% vs. 25% and 19%, respectively, p= 0.070). Eight
percent of the active pts intentionally lost weight.
The inactive pts reported thromboses more often than the
active pts (7% vs. 2% and 5%, respectively, p= 0.038). Falls
during the last 12 months were reported significantly more often
in this group, as well (23% vs. 13% and 10%, respectively, p=
0.007). Thirty-one percent of the sporty active group reported a
splenomegaly, which was in the range to the inactive (33%, p=
ns), but of note: in higher proportion compared to the non-
targeted active (26%, p= 0.026).
TABLE 2 Demographics and current therapies of patients with myeloproliferative neoplasms depending on the diagnosis.
CML PV ET MF
Total sample size n = 183 n = 166 n = 155 n = 117
Demographics
Gender, women 100 (54.6) 113 (68.1) 113 (72.9) 67 (57.3)
Age [years] 51.1 ± 13.6 61.0 ± 12.2 56.7 ± 15.3 59.9 ± 11.1
BMI [kg/m²] 26.4 ± 5.3 25.2 ± 4.7 25.2 ± 4.2 26.3 ± 5.3
School education, ≤10 years 69 (37.7) 71 (42.8) 70 (45.2) 49 (41.9)
Profession, retired 43 (23.5) 75 (45.2) 62 (40.0) 50 (42.7)
Disease-specific therapies n = 171 n = 132 n = 133 n = 108
Tyrosine kinase inhibitor 158 (92.4) –––
Januskinase inhibitors –38 (28.8) 10 (7.5) 56 (51.9)
Cytostatics 7 (4.1) 55 (41.7) 70 (52.6) 19 (17.6)
Interferon 6 (3.5) 35 (26.5) 20 (15.0) 15 (13.9)
Stem cell transplantation 7 (4.1) ––4 (3.7)
Watch-and-wait –13 (9.8) 36 (27.1) 22 (20.4)
Data are presented as the number of participants (%) for categorical variables and as mean ± standard deviation for continuous variables.
CML, chronic myeloid leukemia; PV, polycythemia vera; ET, essential thrombocythemia; MF, myelofibrosis; BMI, Body Mass Index
Felser et al. 10.3389/fonc.2022.1056786
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Association between information level
and physical activity
Two hundred and seventy-two (43%) of all participants stated
that they did not feel sufficiently informed about the importance
and possibilities of PA for their disease. The differences in the level
of information depending on the activity group are presented in
Table 3. Uninformed pts belonged significantly more often to the
group of inactive and non-targeted active pts (p=0.002).Allpts,
regardless of their activity level, expressed their wish to receive more
information about PA.
4 Discussion
This is the first study to investigate the PA behavior of MPN
pts and provide an overview of which factors show an
association with PA in this population. The most important
results are discussed below and information is derived for which
pts may need to lead an active lifestyle for as long as possible.
According to the presented data, the MPN disease and
associated therapies had an impact on PA in 65-81% of the
pts, depending on the MPN subtype. Approximately one in three
pts reported a reduction in PA because of the disease, with the
proportion highest in MF pts and lowest in ET pts. This is about
as expected, as symptom burden varies according to diagnosis
and consequently has different effects on HrQoL. Furthermore,
the prevalence of moderate to severe fatigue, which is associated
with a reduction in PA, is about 50% in MPN pts (1,11).
Of importance is the result that in many MPN pts, depending
on the MPN subtype, fear of certain events - especially infections,
thromboses, bleeding, and skin reactions - had a negative influence
on PA behavior. The reduction was not only limited to sports
activities, but also affected everyday activities. Of particular interest
FIGURE 2
Influence of a myeloproliferative neoplasia disease on self-reported physical activity (n = 620). n, number of patients; CML, chronic myeloid
leukemia (n = 169); PV, polycythemia vera (n = 166); ET, essential thrombocythemia (n = 155); MF, myelofibrosis (n = 117). Bold: statistically
significance, *p≤.05.
Felser et al. 10.3389/fonc.2022.1056786
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FIGURE 3
Anxieties during physical activity in patients with myeloproliferative neoplasms (n = 624). n, number of patients; CML, chronic myeloid leukemia
(n = 178); PV, polycythemia vera (n = 164); ET, essential thrombocythemia (n = 155); MF, myelofibrosis (n = 117). bold: statistically significance, *p≤05,
**p≤001.
FIGURE 4
Physical activity in patients with myeloproliferative neoplasms (n = 559). Data are presented as the number of participants.
1
Activity levels in
leisure time were grouped according to the Godin-Shepard Leisure-Time Physical Activity Questionnaire (GSLTPAQ) into three categories:
“insufficiently active”,“moderately active”, and “active”(15,16).
2
Five stages of the transtheoretical model of behavioral change (SOC) were used
to determine the motivation to participate in sports. In the stages of precontemplation, contemplation, or preparation, patients are not regularly
active in sports. In the stages of action and maintenance, patients are active for at least 20 minutes on at least 3 days per week (17,18).
Felser et al. 10.3389/fonc.2022.1056786
Frontiers in Oncology frontiersin.org07
is our finding that PV and ET pts more frequently reported
anxieties compared to CML and MF pts in regards to the
occurrence of thromboses. This might reflect the fact, that in PV
and ET thromboembolism is often the initial disease complication
that leads to the diagnosis. The rare occurrence of thrombosis in the
presentcohort(3%)suggeststhatthefearespeciallyofPVandET
pts has to be addressed in order to avoid negative effects on PA. The
high proportion of pts in the present study who regularly participate
TABLE 3 Characteristics of patients with myeloproliferative neoplasms depending on the level of physical activity.
Inactive
(1)
(n = 86)
non-targeted
active (2)
(n = 229)
sporty active
(3)
(n = 226)
p-value
group
1vs2
p-value
group
2vs3
p-value
group
1vs3
p-value
c
2
-test
Demographics
Gender, women 64.0 66.7 58.8 .224
Age [years] 59.5 ± 15.5 56.0 ± 12.9 54.7 ± 12.9 .018* .363 .004*
BMI [kg/m²] 26.6 ± 5.2 25.8 ± 4.4 25.3 ± 4.8 .319 .072 .013*
School education, ≤10 years 47.6 43.2 32.3 .095
Profession, retired 42.9 36.9 31.0 .214
Health-related quality of life
1
60.1 ± 22.7 63.2 ± 21.2 73.2 ± 19.7 .266 ≤.001** ≤.001**
Symptoms
2
Fatigue 45.6 ± 31.5 43.9 ± 29.8 33.0 ± 28.1 .656 ≤.001** ≤.001**
Bone and muscle pain 37.3 ± 31.9 33.1 ± 28.9 25.0 ± 27.6 .467 ≤.001** .005*
Concentration problems 31.7 ± 28.6 35.0 ± 27.5 23.9 ± 25.5 .283 ≤.001** .024*
Itching 16.7 ± 24.6 16.9 ± 24.2 13.3 ± 22.8 .430 .027* .438
Abdominal discomfort 20.6 ± 26.9 19.4 ± 26.6 15.7 ± 23.5 .605 .236 .156
Early satiety 24.3 ± 27.0 18.6 ± 25.6 16.2 ± 23.3 .082 .394 .016*
Night sweats 20.8 ± 24.7 21.2 ± 29.0 16.8 ± 26.7 .530 .204 .069
Fever (> 37,8°C) 0.9 ± 3.4 1.2 ± 4.8 1.5 ± 6.7 .177 .560 .330
Weight change during last 3 mths .070
weight gain, yes 29.4 24.6 18.7
unintended weight loss, yes 9.4 9.2 8.4
intended weight loss, yes 0.0 8.3 8.4
Current side effects/concomitants
Skin reactions, yes 41.9 48.0 40.3 .267
Splenomegaly, yes 32.6 25.8 31.0 .026*
increased bleeding tendency, yes 22.1 33.3 31.4 .242
Thrombosis during last 3 month, yes 7.0 1.7 4.9 .038*
Falls during last 12 months, yes 23.3 13.1 9.7 .007*
Information on physical activity
felt sufficiently informed, yes 47.1 48.7 63.6 .002*
more information desired, yes 68.6 67.1 63.6 .603
Data are presented as mean ± standard deviation for continuous variables and as percentage of patients for categorical variables.
Mean differences for continuous variables were tested using Mann-Whitney U test and c
2
-test for categorical variables.
n, number of patients; BMI, Body Mass Index.
1
range 0-100, higher values represent high health-related quality of life;
2
range 0-100, higher values represent more discomfort.
bold: statistically significance, *p≤.05, **p≤.001.
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in sports despite anticoagulationand/orskinreactionsuggeststhat
these symptoms do not represent a limitation to sports activities.
Thenumerousexerciseinterventions available for pts following
high-dose chemotherapy and hematopoietic stem cell
transplantation also suggests that exercise is safe for pts at
increased risk of bleeding and infection, and that pts may benefit
from numerous positive effects (20).Itcannotbeexcludedthatthe
COVID-19 pandemic prevailing at the time of the survey increased
the fear of infection, which was not further specified. The present
results suggest that MPN pts should be informed about the real risk
of thrombosis or serious bleeding during PA. To support patients’
active lifestyles, ways to reduce the risk of infection, bleeding, and/or
skin reactions during daily activities and sports should be
emphasized (e.g., hand disinfection, face mask during group
exercise, low-injury sports/forms of exercise, and if necessary,
refrain from water sports, add sun protection, etc.).
According to the presented data, 62% of MPN pts were
sufficiently physically active in their daily lives at the time of the
survey (self-reported), and 43% stated that they regularly played
sports. These are unexpectedly high percentages and might be due
to the survey design. Due to the voluntariness, it cannot be ruled out
that more pts with an affinity for sports took part in the survey. In
addition, 10% of the participants did not answer the questions on
PA behavior or answered them inadequately and were excluded
from the analysis. Furthermore, the cohort is quite young with an
average age of 57 years and it is known that PA tends to decrease
with age (21). Likewise, socially desirable responses cannot be
excluded. Based on the results of large American and British
cohort studies of cancer survivors, it must be assumed that the
proportion of insufficiently physically active MPN pts is higher than
the results of this study show (22,23). Regardless, the participants
could be divided into three groups (inactive, non-targeted active,
and sporty active) according to their PA statements, which were
sufficiently large for the statistical analyses.
Among physically active pts, the proportion of pts with
increased bleeding tendency or skin reactions is as high as among
inactive pts. Consequently, these side effects/concomitants are not,
or only to a limited extent, barriers to PA or sports. Mean
comparisons showed comparable symptom burden and HrQoL
for the inactive and non-targeted active pts. This suggests that a lack
of motivation is the reason for inactivity rather than symptom
burden. As behaviors tend to become entrenched over time, they
are often difficult to change. To motivate previously inactive MPN
pts to adopt an active lifestyle, a psychologist’sinvolvementmaybe
beneficial. The most effective strategies to motivate cancer pts to be
more physically active in the long term include motivational
interviewing, coaching, and Bandura’s socio-cognitive learning
(model learning) approach (24).
In all groups, fatigue, bone and muscle pain, and concentration
problems represented the most common severe symptoms. The
reported prevalence and severity of these symptoms is comparable
to results of other studies (1,11). Inactive and non-targeted active
pts showed no differences in symptom burden and HrQoL. Based
on the findings that PA and fatigue correlate negatively, and PA and
HrQoL correlate positively (5,11), this is an unexpected result.
However, the result could be an indication that it is not the amount
of PA that is decisive for the symptom burden, but the quality/
targeting of the PA. This is also in line with the general
recommendations for reducing fatigue. Moderate-intensity
exercise is recommended here, as the effect is unlikely at low
intensities. Moreover, there is no evidence for a dose-response
relationship (25).
The lower symptom burden and higher HrQoL of the sporty
active pts in our study is consistent with the assumption of Eckert
et al. (13) that targeted PA could also have positive effects in MPN
pts. However, as there is a bidirectional relationship between
symptom burden or HrQoL and PA, no statement on causality
can be made on the basis of the available cross-sectional data. This
should be investigated in subsequent studies. Due to the small
differences in symptom burden and HrQoL between the groups
(about 10%), it is assumed that the effects of targeted PA on
symptoms and HrQoL in MPN pts are modest. This is also
confirmed by the results of Huberty et al. (26,27). Thus, small to
moderate effect size for sleep disturbance, pain intensity, anxiety,
and depression were generated by approximately one hour of yoga
training per week over a period of 12 weeks. Although Pedersen
et al. (28) demonstrated that a 12-week self-exercising program,
after a 5-day interdisciplinary exercise-based rehabilitation
intervention, significantly increased physical performance of
MPN pts, but no improvements were seen with respect to
HrQoL and fatigue. However, since PA has a multitude of health
potentials, MPN pts should be motivated to be physically active
regularly and for as long as possible. The available data suggest that
both daily activities and sports can reduce the risk of falls and
regulate body weight. The fact that 12% of pts surveyed reported
being more conscious and/or increasing their PA since diagnosis
suggests that adequate patient education can alleviate potential fears
and possibly increase motivation to engage in PA or sports. The
focus should be specifically on older and physically inactive pts (29).
Similarly, overweight MPN pts should be addressed, appropriately
educated, and motivated to be physically active. Reducing obesity in
MPN pts might have several positive effects on outcome. Reducing
obesity associated diseases such as atherosclerosis and risk factors is
a general goal. In particular as some MPN treatment approaches
such as TKI-treatment or stem cell transplantation might increase
the risk for e.g. atherosclerosis themselves. Furthermore, obesity
might influence pharmacokinetics of drugs used in MPN treatment,
although data is limited (30–33).
The presented data is based on a large cohort, but due to the
survey design, there are inevitable limitations that should be
taken into consideration when interpreting the data. First, due to
the online format, no information is available on how many
potential participants were informed about the study and
declined to participate. Due to the high proportion of online
questionnaires, a bias towards more women and “younger”
respondents is suspected. Even though it is known that
Felser et al. 10.3389/fonc.2022.1056786
Frontiers in Oncology frontiersin.org09
women often report a higher symptom burden, we suspect that
the bias of the results due to the unbalanced participation of the
genders is small (34). This assumption is strengthened by the
fact that the proportion of women in the three activity groups
did not differ significantly. Second, all data were assessed
retrospectively. Third, due to the cross-sectional design of the
study, it is not possible to distinguish between cause and effect in
terms of symptom burden and PA. Regardless of whether and to
what extent individual symptoms can be reduced by PA, our
results highlight the importance of PA because of its multitude of
other potentials, such as reducing the risk of falls and weight
control. Forth, in order to reduce the length of the questionnaire,
no validated questionnaire was used for the assessment of
HrQoL, but a VAS scale from 0 to 100. Since the VAS allows
a more differentiated assessment of HrQoL compared to a Likert
scale, it can be assumed that the HrQoL of cancer pts can be
measured just as adequately (35). A major advantage of our
study is the relatively large sample size. This representative
sample of the population-based study thus enables the transfer
of the results to clinical practice.
5 Conclusion
In conclusion, it could be shown that the majority of MPN pts
change their self-reported PA behavior due to the MPN disease or
therapy. About one third of all MPN pts reduce the amount of PA,
especially pts with PV and MF. In addition to fears, especially of
infection, thrombosis and bleedings depending on the MPN
subtype, higher age and motivation level also seem to influence
PA. Sporty pts have a lower symptom burden and higher HrQoL
than non-sporty pts. Physically inactive pts have a significantly
higher prevalence of falls and higher BMI compared to physically
active pts. Inactive and non-targeted active pts were significantly
less likely to be informed about the importance and possibilities of
PA. Our data clearly suggest that PA information and education, as
well as sports programs, should be integrated into the treatment of
MPN pts. Further studies, especially longitudinal studies are needed
to verify the results of the survey study.
Data availability statement
The raw data supporting the conclusions of this article will
be made available by the authors, without undue reservation.
Ethics statement
The studies involving human participants were reviewed and
approved by Ethics Committee of the University of Rostock.
Written informed consent for participation was not required for
this study in accordance with the national legislation and the
institutional requirements.
Author contributions
Conception and design: SF, CJ. Statistical analysis and
interpretation: SF, JR, CJ. Data collection: PC, HA-A, SS, L-OM,
JuG, JaG, VK-K. Writing the article: SF, JR, CJ. Critical revision of
thearticle:SF,JR,PC,HA-A,SS,L-OM,JuG,JaG,VK-K,CJ.
Obtained funding: SF. Overall responsibility: SF, CJ. All authors
contributed to the article and approved the submitted version.
Funding
The study was supported by the East German Study Group
Hematology and Oncology (OSHO), file number OSHO #97.
Acknowledgments
The authors would like to thank the LeukaNET/Leukemia-
Online and the German, Austrian and Swiss MPN Network for
her support for assistance in recruiting MPN patients for
conducting online survey.
Conflict of interest
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed
or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/
fonc.2022.1056786/full#supplementary-material
Felser et al. 10.3389/fonc.2022.1056786
Frontiers in Oncology frontiersin.org10
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