br Because I found out that if
“Because I found out that if I burned 1, 2, 3, 4, 5, 600 calories every hour, then I would not be able to catch up (with that). Meaning, I would experience a bigger weight loss by exercising. I simply could not aﬀord it. So, I stopped” (ID 13, 69-year-old male with pancreatic cancer)
Despite positive attitudes towards exercise, most informants ex-pressed that it was very diﬃcult to stay active in their new everyday life with cancer, and only few were still involved in structured exercise. The informants who had managed to stay physically active during treatment described how exercise provided new energy, gave a mental break from negative feelings of being seriously ill, and at times had the ability to reduce fatigue. More specifically, being physically active altered feel-ings of fatigue into more normal and well-known feelings of being physically tired.
“You might call it a more natural tiredness. You have a reason for feeling tired, right? Of course, there is also a reason for feeling tired from cancer treatment. But in that case, it is just inflicted upon you.” (ID 20, 72-year old male with biliary tract cancer)
Most of the informants who had remained physically active during treatment had also been active for a large part of their lives and therefore knew and appreciated the positive eﬀects of exercise.
3.2. Comorbidities and external circumstances prevent physical activity
Several barriers towards physical activity (PA) were identified. Everyday life in their current situation was already filled with practical challenges, and there was no reserve of mental Okadaic acid to start engaging in new activities. Even normal circumstances like bad weather could make PA unmanageable. Other changes in daily life were for some more than enough to comprehend, and therefore PA was not their main priority.
“I have more than enough to handle with carpenters working at my house, handling oncological treatment and everything else that is going on now. There is no energy for anything else other than just getting by” (ID 1, 85-year old female with NSCLC)
Passing events across the life span changed the informants’ normal exercise routines. Some described that their exercise routines had been ruined because their usual exercise facility had closed, because their dog had died, or because their spouse or usual training partner was not able to participate anymore. Starting over and creating new exercising routines could be an insurmountable task.
“And then he [best friend] could not manage to exercise with me anymore, and that spoiled a lot for both of us” (ID 22, 76-year-old male with biliary tract cancer)
The informants experienced that physical limitations made it diﬃ-cult to participate in team sports or to exercise at a gym. They were not sure how much and what kind of exercise they were capable of and felt unsure about their own physical boundaries. Some informants who had COPD or dyspnea felt unsafe about exercising - especially without su-pervision from a HCP, as acute dyspnea provoked feelings of distress and anxiety.
“I cannot just go to the gym down here and say that I have this much lung capacity left. They would not know where to set the level. Surely, I cannot exercise at the same level as healthy people” (ID 18, 77-year-old male with NSCLC)
Some informants described that the greatest physical limitations were not even related to their current cancer, but to comorbidities or musculoskeletal disorders (osteoarthritis or unspecified hip and back pain). Sometimes, the current life situation and treatment schedule prevented them from getting other medical conditions examined by their general practitioner, as they did not have the energy or because they could not overcome the consequences. Therefore, these physical limitations remained barriers that hindered PA.
“I had back surgery for spinal stenosis. It went ok for a while, but then the pain started in the pelvis and spread down to the legs. So, it is probably something with the nerves. But I cannot really deal with anything else than this [oncological treatment] right now” (ID 1, 85-year-old female with NSCLC)
3.3. Fatigue overshadows life
The informants described fatigue as being the most profound bar-rier. Fatigue interrupted their normal routines, and even daily house-keeping activities such as vacuuming suddenly became major tasks to overcome. Fatigue was described as an overwhelming feeling that just overshadowed everything else.
“Maybe I sleep more now. Sometimes I need a nap again after breakfast” (ID 6, 65-year-old female with NSCLC)
Fatigue was frequently described in combination with other symp-toms. Some experienced fatigue and loss of appetite/anorexia, or fa-tigue and dyspnea as symptoms that mutually aﬀected each other. The interaction between diﬀerent symptoms was described by an informant with NSCLC who had severe fatigue in the period up to cancer diag-nosis, but who experienced symptom relief after starting treatment with immunotherapy.