Community-based exercise programs for cancer survivors: a scoping review of practice-based evidence

Expanding active living after cancer to underserved cancer survivors and their caregivers

BACKGROUND

Physical activity improves physical and psychological health in cancer survivors. This study evaluated Active Living After Cancer (ALAC), a community-based program to improve physical activity, physical function, and quality of life (QOL) in minority and medically underserved cancer survivors and their caregivers.

METHODS

Participants completed 12 weekly ALAC sessions and assessments of physical activity, physical functioning, and QOL at baseline and follow-up (week 12). Paired samples t tests were used to assess changes in outcomes over time.

RESULTS

A total of 540 cancer survivors (mean age = 61.1 [SD = 11.3] years) and 87 caregivers (mean age = 62.3 [SD = 13.1] years) were enrolled. Most were women (91.4%), Hispanic (61.1%) or non-Hispanic Black (19.3%), and medically underserved (86.4%). The percent of cancer survivors meeting physical activity recommendations increased from 28.9% to 60.2% (d = 0.75), and the number of sit-to-stand repetitions in a 30-second period increased from 12.3 to 14.3 (d = 0.39) from 0-12 weeks. Cancer survivors reported statistically significant improvements in physical (t score Δ = 1.7, d = 0.06) and mental (t score Δ = 2.3, d = 0.31) health-related QOL. Caregivers also improved their physical activity, physical function, and QOL, and there were no statistically significant differences between breast and other cancer survivors and between cancer survivors and caregivers.

CONCLUSIONS

The ALAC program demonstrated increased physical activity, physical function, and QOL in medically underserved cancer survivors and their caregivers. Furthermore, ALAC was successfully implemented by community partners and serves as a good model for reaching medically underserved cancer survivors and improving survivorship. Additional efforts are warranted to further extend reach, improve cancer survivorship, and reduce cancer health disparities among underserved cancer survivors.

The Physical Activity and Cancer Control (PACC) framework: update on the evidence, guidelines, and future research priorities

BACKGROUND

We proposed the Physical Activity and Cancer Control (PACC) framework in 2007 to help organise, focus, and stimulate research on physical activity in eight cancer control categories: prevention, detection, treatment preparation/coping, treatment coping/effectiveness, recovery/rehabilitation, disease prevention/health promotion, palliation, and survival.

METHODS

This perspective paper provides a high-level overview of the scientific advances in physical activity research across cancer control categories, summarises current guidelines, updates the PACC framework, identifies remaining and emerging knowledge gaps, and provides future research directions.

RESULTS

Many scientific advances have been made that are reflected in updated physical activity guidelines for six of the cancer control categories apart from detection and palliation. Nevertheless, the minimal and optimal type, dose, and timing of physical activity across cancer control categories remain unknown, especially for the understudied population subgroups defined by cancer type, age, race/ethnicity, and resource level of regions/countries.

CONCLUSION

To achieve the full benefit of physical activity in cancer control, future research should use innovative study designs that include diverse at-risk populations and understudied cancer sites. Additionally, effective behaviour change strategies are needed to increase physical activity levels across populations that use implementation science to accelerate the translation from evidence generation into practical, real-world interventions.

Community-Based Multidimensional Cancer Rehabilitation in Norway: A Feasibility Study

BACKGROUND

Cancer survival is often accompanied by late effects that can be mitigated by tailored rehabilitation. In Norway, this has traditionally been offered as residential programs, whereas community-based cancer rehabilitation programs are lacking.

OBJECTIVE

This study aimed to assess the feasibility and acceptability of a newly developed community-based multidimensional cancer rehabilitation program in Norway.

METHODS

A feasibility study with a mixed methods explanatory sequential design was implemented. The intervention was a 12-week group-based rehabilitation program comprising 5 components: goal setting, physical exercise, psychoeducation, individual follow-up consultations, and peer support. Feasibility was assessed through recruitment, retention, and intervention delivery. Acceptability was assessed through intervention adherence and participant evaluation. Qualitative data were generated from focus group interviews. Statistical analyses were descriptive, and qualitative data were transcribed and analyzed using framework analyses.

RESULTS

Sixty participants started, and 55 completed the 12-week rehabilitation program. The majority were female (80%), and the mean age was 56 years. The largest diagnostic group was breast cancer (42%). Retention was high (92%), as were adherence rates for all intervention components. The exercise component was rated the most beneficial, followed by individual consultations and peer support. Qualitative findings contributed to explaining the high adherence and positive evaluation.

CONCLUSION

High retention, strong adherence, and positive evaluation imply that the community-based program was feasible and acceptable to cancer survivors.

IMPLICATION FOR PRACTICE

The results will aid intervention refinement and contribute to a future randomized controlled trial to examine its effectiveness. If successful, the rehabilitation program could be implemented in the Norwegian Cancer Pathway "Home."

A two-arm non-randomised trial of MedEx IMPACT: a community-based, physical activity behaviour change intervention for survivors of cancer

PURPOSE

This two-arm non-randomised trial examined the short- and long-term effects of a usual care (UC) community-based exercise programme (MedEx Move On (MMO)), and UC combined with a physical activity (PA) behaviour change (BC) intervention (MedEx IMproved PA after Cancer Treatement (MedEx IMPACT)) on PA levels, cardiorespiratory fitness (CRF) and quality of life (QoL) among survivors of cancer.

METHODS

Cancer survivors referred to MMO were recruited (n = 191; mean age (± SD) 56 (± 10y), 73% female). Eighty-seven participants were assigned to UC, and 104 participants were assigned to the MedEx IMPACT intervention group (MI). UC and MI both received twice-weekly supervised exercise classes for 12-weeks. MI also received an independent PA programme, 4 PA information sessions and a 1:1 exercise consultation during the 12-week programme. Assessments of physical and psycho-social health, including 6-day accelerometry, the 6-min time trial and the Functional Assessment of Cancer Therapy-General QoL questionnaire, were conducted at baseline (T1), post-intervention (T2) and 3 months following programme completion (T3).

RESULTS

Linear mixed-model analyses of variance demonstrated significant main effects for time for both groups from T1 to T2 with increases in objectively measured daily steps (p < 0.05), CRF (p < .001) and QoL (p < .01), which were maintained for CRF (p < .001) at T3. MI participants also maintained increases achieved at T2, in steps and QoL, at T3 (p < 0.01).

CONCLUSION

Twelve weeks of twice-weekly supervised exercise was effective in increasing PA, CRF and QoL among survivors of cancer. MI resulted in the maintenance of all improvements achieved 3 months following programme completion.

"It has to be more than exercise": exploring multiple perspectives to community-based exercise program design for persons with breast cancer

PURPOSE

Connecting persons with cancer to exercise resources and/or supports requires a diverse team of professionals. As such, there is merit to engaging multiple individuals or "partners" along the cancer pathway to explore the relevant features of community-based exercise program (CBEP) design. The purpose of this study was to explore multi-partner perspectives to CBEP design for persons diagnosed with breast cancer (PWBC) to inform the implementation of a CBEP in a local setting.

METHODS

PWBC, health care professionals and qualified exercise professionals participated in one of four 60-min focus group discussions. Rich dialogue about preferred program environments, program delivery teams, and core program practices was encouraged using a semi-structured discussion guide. Focus groups were audio recorded, transcribed verbatim, and analyzed using inductive thematic analysis.

RESULTS

Five main themes were identified based on focus group discussions, each pointing to an important feature of CBEP design for PWBC. Themes included the desire for CBEPs to incorporate elements designed to improve cancer literacy, provide opportunities to participate with peers, foster self-efficacy, prioritize program accessibility, and meaningfully integrate CBEPs within a network of supportive cancer care.

CONCLUSION

The collective effect of fostering such elements in CBEPs may serve to increase the uptake and maintenance of exercise among PWBC; ultimately enhancing their overall well-being and quality of life.

Evaluating individual level change in physical function response following an exercise program for cancer survivors

PURPOSE

Cancer survivors physical function response to exercise programs at the group level is well-established. However, to advance toward a more personalized approach in exercise oncology, a greater understanding of individual response is needed. This study utilized data from a well-established cancer-exercise program to evaluate the heterogeneity of physical function response and explore characteristics of participants who did vs. did not achieve a minimal clinically important difference (MCID).

METHODS

Physical function measures (grip strength, 6-min walk test (6MWT), and sit-to-stand) were completed pre/post the 3-month program. Change scores for each participant and the proportion achieving the MCID for each physical function measure were calculated. The independent t-tests, Fisher's exact test, and decision tree analyses were used to explore differences in age, body mass index (BMI), treatment status, exercise session attendance, and baseline value between participants who achieved the MCID vs. those who did not.

RESULTS

Participants (N = 250) were 55 ± 14 years old, majority female (69.2%), white (84.1%), and diagnosed with breast cancer (36.8%). Change in grip strength ranged from - 42.1 to + 47.0 lb, and 14.8% achieved the MCID. Change in 6MWT ranged from - 151 to + 252 m, and 59% achieved the MCID. Change in sit-to-stand ranged from - 13 to + 20 reps, and 63% achieved the MCID. Baseline grip strength, age, BMI, and exercise session attendance were related to achieving MCID.

CONCLUSIONS

Findings illustrate wide variability in the magnitude of cancer survivors' physical function response following an exercise program, and that a variety of factors predict response. Further investigation into the biological, behavioral, physiological, and genetic factors will inform tailoring of exercise interventions and programs to maximize the proportion of cancer survivors who can derive clinically meaningful benefits.

Multimodal Physical Exercise and Functional Rehabilitation Program in Oncological Patients with Cancer-Related Fatigue-A Randomized Clinical Trial

The increase in life expectancy and survival time implies an increase in the possible side-effects of pharmacological treatments in patients. Cancer-related fatigue is one of these side-effects. The main objective of this study was to evaluate the effects of a multimodal program of physical exercise and functional rehabilitation on asthenia, pain, functional capacity, and quality of life in cancer patients with cancer-related fatigue.

METHODS

This was a randomized, parallel-controlled clinical trial, with two arms (experimental and control group), and it was conducted over the course of a year in the Oncology Hospitalization Unit at the University Hospital of Salamanca, Spain. Participants (n = 48) were assessed at three points during the study. The first assessment was prior to hospital discharge, the second assessment was after 15 days, and the final assessment was at one month post-hospital follow-up. The intervention lasted one month. The main variables studied were the dependency levels (Barthel), cancer-related fatigue (FACT-An), health-related quality of life (EuroQoL-5D), functional capacity (SPPB), and kinesiophobia (TSK-F).

RESULTS

Sample size (n = 44). Mean age 63.46 ± 12.36 years. Significant differences between control and experimental group participants in Barthel, FACT-An, TSK-F, and SPPB scores at follow-up and final assessment.

CONCLUSIONS

There are beneficial effects of a multimodal physical exercise and functional rehabilitation program in improving the autonomy of cancer-related fatigue patients.

A Group-Based, Videoconference-Delivered Physical Activity Program for Cancer Survivors

Introduction/Purpose

Virtually supervised, group-based exercise presents an innovative way to expand the reach of exercise-oncology programs and help cancer survivors increase physical activity (PA) and connect with other participants. This study examined the feasibility, acceptability, and preliminary effects of a group-based PA program delivered exclusively using videoconferencing software.

Methods

This study used a single-group pre-post design. The 8-wk program consisted of aerobic and resistance exercise sessions once per week and three PA behavior change discussion sessions in groups of four to six. Feasibility was determined by enrollment, retention, safety, and adherence. Postprogram surveys evaluated acceptability using a Likert scale and open-ended responses. Changes in PA (Godin Leisure-Time Exercise Questionnaire), quality of life (QOL; Functional Assessment of Cancer Therapy- General), and upper and lower body muscular endurance (bicep curl and sit-to-stand test) were also evaluated.

Results

Enrollment was feasible (n = 61 of 65 who expressed interest in the program), and retention (86.9%) and adherence (88% for exercise, 91% for discussion) were high; no adverse events were reported. Participants (mean age, 59.9 ± 10.1 yr; 96.2% female; 64.2% ovarian cancer, 28.3% breast cancer, 7.5% other cancer) reported they enjoyed the program (median, 7 of 7), and videoconferencing software was easy to use and had good video and audio quality (median, 5 of 5). From preprogram to postprogram, participants increased their weekly minutes of aerobic (mean (SD) change, 82.4 (144.2)) and resistance (mean (SD) change, 31.9 (42.7)) PA; sit-to-stand (mean (SD) change, 1.4 (3.9)) and bicep curl (mean (SD) change, 5.3 (6.8)) repetitions; and emotional (mean (SD) change, 0.82 (2.3) points), functional (mean (SD) change, 1.2 (3.6) points), and total QOL (mean (SD) change, 3 (7.9) points; all P < 0.05).

Conclusions

A group-based PA program delivered using videoconference technology is feasible and acceptable for cancer survivors, and may increase PA and improve physical fitness and some aspects of QOL. A larger, controlled intervention is needed to determine efficacy, as well as pragmatic studies to directly compare this approach with conventional strategies (i.e., face-to-face programs).

Feasibility and acceptability of home-based strength training in endometrial cancer survivors

PURPOSE

Physical activity is important for healthy cancer survivorship, yet many endometrial cancer survivors do not participate in recommended muscle-strengthening activity. The purpose of this study was to determine the feasibility of home-based muscle strengthening activity in endometrial cancer survivors.

METHODS

Forty post-treatment endometrial cancer survivors were enrolled in a randomized trial, of twice-weekly home-based strength exercise versus wait-list control. The intervention included educational materials, exercise equipment (dumbbells, resistance bands), and support/feedback via video coaching sessions. Participants completed the exercises twice per week for 10 weeks, with a 5-week follow-up period. Feasibility was measured by program adherence, as well as safety of and satisfaction with the study.

RESULTS

On average, participants were 60.9 years old (SD = 8.7), had a BMI of 39.9 kg/m2 (SD = 15.2), and were 2.9 years (SD = 1.2) since diagnosis. The majority (83%) had stage I disease at diagnosis. Seventy-five percent adhered to the exercise prescription of twice/week, with 85% of participants missing fewer than 3 of the workouts. Forty percent of participants continued workouts during the 5-week follow-up. Participants were highly satisfied with intervention. No injuries or adverse everts occurred.

CONCLUSION

This home-based program was feasible in endometrial cancer survivors. While adherence was measured, future research should focus on long-term maintenance of exercise and should explore progressions and modifications of exercises at a distance for various abilities.

IMPLICATIONS FOR CANCER SURVIVORS

Muscle strengthening activities are recommended for all cancer survivors. This study shows that a home-based muscle strengthening exercise is feasible in endometrial cancer survivors.

Determinants of exercise adherence and maintenance for cancer survivors: Implementation of a community-based group exercise program. A qualitative feasibility study

Objective

Despite verified knowledge that physical exercise plays an important part in recovery after cancer treatment, multiple studies have shown that maintaining a physically active lifestyle after cancer is challenging. There is a need for qualitative studies to increase understanding into patient experiences and perspectives, and facilitate the design of more sustainable exercise program. This qualitative descriptive feasibility study explores experiences from the implementation of a novel four-month community-based group exercise program for cancer survivors within municipality health service after completion of rehabilitation in the specialist health care service.

Methods

Fourteen cancer survivors participated in focus group interviews after completing Rehabilitation: Physical activity and Coping - feasibility study. Data were analyzed using the systematic text condensation method.

Results

We identified a main category, Determinants for exercise adherence and maintenance and four subcategories: peer-support, environment, structure and knowledge.

Conclusion

A social and supportive exercise environment promotes exercise adherence and maintenance among cancer survivors. This knowledge can be useful for further efforts to implement high quality community-based group exercise programs for cancer survivors.

Innovation

This study adds knowledge of survivors' experience of a novel community-based group exercise program in clinical practice and can promote the implementation of sustainable community-based exercise programs for cancer survivors.

Light-intensity and moderate-to-vigorous intensity physical activity among older adult breast cancer survivors with obesity: A narrative review

BACKGROUND

With an aging population, rising incidence of breast cancer, improved survival rates, and obesity epidemic, there will be a growing population of older adult breast cancer survivors with obesity. This complex population, often with multimorbidity, is at risk for several poor health outcomes, including recurrence, cardiovascular disease, dementia, and diabetes, and a number of deleterious symptoms, including a worsened inflammatory profile, breast cancer- related lymphedema, mobility disability, cognitive impairment, anxiety, and depressive symptoms. A wealth of meta-analytic and randomized controlled trial evidence show that adherence to World Health Organization and 2018 United States Physical Activity guidelines-based levels of moderate-to-vigorous physical activity (MVPA) reduces risk of all-cause mortality, and improves symptoms. However, few survivors engage in recommended levels of MVPA, and symptoms related to their multimorbidity may preclude engaging in sufficient levels of MVPA. Additional research of MVPA in this population is warranted; however, understudied light-intensity physical activity (LIPA) may be a more pragmatic target than MVPA among this complex population facing extensive challenges meeting MVPA recommendations. Large benefits are likely to occur from increasing these survivors' total activity, and LIPA prescriptions may be a more pragmatic approach than MVPA to aid this transition.

METHODS

We present a broad, narrative review of the evidence for MVPA and LIPA in this population on an array of health outcomes across the translational science spectrum (clinical, implementation, and public health), and identify a number of directions for future research focused on understanding the potential diverse health effects of LIPA.

CONCLUSION

Additional LIPA research is warranted, as LIPA prescriptions may be a pragmatic strategy to effectively promote physical activity to this complex population.

Cancer-related fatigue mediates the relationships between physical fitness and attendance and quality of life after participation in a clinical exercise program for survivors of cancer

PURPOSE

Cancer-related fatigue (CRF) is a common and limiting symptom reported by survivors of cancer, negatively impacting health-related quality of life (HRQoL). Exercise improves CRF, HRQoL, and physical fitness in survivors. Prospective research trials have shown that exercise-associated fitness improvements effects on HRQoL are mediated by CRF; however, this has not been investigated in a pragmatic real-world setting. This study utilizes data from a large heterogenous population of survivors participating in a clinical exercise program to investigate this mediation effect, as well as effects of program attendance.

METHODS

Data were collected from 194 survivors completing the BfitBwell Cancer Exercise Program (July 2016-February 2020). Changes in HRQoL, CRF, and fitness were calculated and program attendance collected. Basic correlation analyses were performed. Linear regression analyses were performed to assess mediation by CRF.

RESULTS

All measures of CRF, HRQoL, and physical fitness significantly improved following the exercise program. Improvements in physical fitness were significantly correlated with improvements in HRQoL (r = 0.15-0.18), as was program attendance (r = 0.26) and CRF (r = 0.59). The effects of physical fitness and program attendance on HRQoL were at least partially mediated by the effects of CRF.

CONCLUSION

This study extends research findings on how exercise programs improve HRQoL in survivors of cancer to a real-world setting. Results indicate that clinical exercise programs should target reductions in CRF in survivors (during or after treatment) through improvements in physical fitness to improve HRQoL and that high attendance should be encouraged regardless of fitness changes.

Studying the implementation of exercise oncology interventions: a path forward

Introduction/Purpose

Extensive scientific evidence supports exercise benefits after a cancer diagnosis and the field now needs to focus on elucidating effective strategies for implementing exercise evidence-based interventions (EBIs) for cancer survivors.

Methods

This paper brings together three implementation efforts to describe pragmatic observations and strategies when implementing exercise oncology EBIs in non-research settings. From these projects, we report on common implementation barriers and facilitators. We then mapped these observations and strategies on to the phases and processes described in the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework.

Results

The first implementation project used key stakeholders' perspectives to develop a toolkit to implement BEAT Cancer (Better Exercise Adherence after Treatment for Cancer), a self-managed intervention led by fitness professionals. The second project adapted a physical activity behavior change intervention (Active Living after Cancer) for use in the broader community. The third project adapted an in-person exercise intervention in a community setting (Physical Activity and Lymphedema) into an out-patient rehabilitation setting, including home-based intervention elements (Strength After Breast Cancer). We retrospectively collated and operationalized the implementation strategies based on the Experts Recommending Implementation Change (ERIC) study. The most common implementation barriers were related to funding, organizational capacity and training, relationship building, patient referral, and engagement with patients.

Conclusions

These implementation strategies provide initial starting points for the implementation of exercise oncology EBIs in clinical and community settings while also serving as examples for future implementation research to advance the translation of exercise oncology evidence.

Impact of community-based exercise on fatigue in early breast cancer survivors: identifying potential determinants of change

BACKGROUND

Exercise has been shown to reduce fatigue in early breast cancer survivors (EBCS), though it is unclear if these results translate to community-based exercise settings. Mechanisms that influence changes in fatigue seen after exercise are also poorly understood. This study sought to evaluate the impact of community-based exercise and identify associations of fatigue in EBCS.

METHODS

Twenty-nine EBCS and 13 non-cancer controls (CON) enrolled. Pre/post-intervention measurements included measures of fitness/function, balance, and adherence/compliance as well as self-reported measures of fatigue, health-related quality of life (HRQOL), well-being, self-efficacy, and physical activity. Both groups participated in a supervised 16-week aerobic + resistance exercise intervention. A mixed model ANOVA and Cohen's D effect size assessed fatigue changes, and univariable linear regressions identified fatigue associations.

RESULTS

Fatigue improved for EBCS (- 2.6, Cohen's D = 0.51) but not CON (0.0, Cohen's D = 0.02); no interaction effect was observed. Post-intervention fatigue in EBCS was associated with better QOL (R² = 0.387; p < 0.01), depression (R² = 0.251; p < 0.01), self-efficacy, (R² = 0.453; p < 0.01), outcome expectations from exercise (R² = 0.254; p < 0.01), balance (R² = 0.167; p < 0.05), and the 6-minute walk test (R² = 0.193; p < 0.05). EBCS improvements in fatigue were associated with improvements in self-reported physical health (R² = 0.425; p < 0.01), depression (R² = 0.233; p < 0.01), pain (R² = 0.157; p < 0.05), outcome expectations from exercise (R² = 0.420; p < 0.01), and the 6-minute walk test (R² = 0.172; p < 0.05). Less fatigue in the CON group was shown be associated with better sleep quality (R² = 0.309; p < 0.05) and pain (R² = 0.259; p < 0.05).

CONCLUSION

Community-based exercise appears beneficial for alleviating fatigue in EBCS. These improvements may be driven by parallel improvements in psychosocial outcomes and objectively measured functional outcomes.

Cross-sector co-creation of a community-based physical activity program for breast cancer survivors in Colombia

Benefits of physical activity (PA) in breast cancer survivors (BCS) are well established. However, programs to promote PA among BCS tailored to real-world contexts within low- to middle-income countries are limited. Cross-sector co-creation can be key to effective and scalable programs for BCS in these countries. This study aimed to evaluate the networking process to engage multisector stakeholders in the co-creation of a PA program for Colombian BCS called My Body. We employed a mixed-methods design including semistructured interviews, workshops and a social network analysis of centrality measures to assess stakeholders' engagement, resources and skills enabling the collaborative work, challenges, outcomes and lessons learned. The descriptive analysis and the centrality measures of the network revealed that 19 cross-sector stakeholders engaged in the My Body collaborative network. Through ongoing communication and cooperation, My Body built relationships between the academic lead institutions (local and international), and local and national public, private and academic institutions working in public health, sports and recreation, social sciences and engineering fields. The outcomes included the co-creation of the community-based PA program for BCS, its implementation through cross-sector synergies, increased relationships and communications among stakeholders, and successful dissemination of evidence and project results to the collaboration partners and other relevant stakeholders and community members. The mixed-methods assessment enabled understanding of ways to advance cross-sector co-creation of health promotion programs. The findings can help to enable continued development of sustainable cross-sector co-creation processes aimed at advancing PA promotion.

A Randomised, Comparative, Effectiveness Trial Evaluating Low- versus High-Level Supervision of an Exercise Intervention for Women with Breast Cancer: The SAFE Trial

The aim of this comparative, effectiveness trial was to evaluate the safety, feasibility and effect of an exercise intervention delivered via low-level versus high-level supervision. The target population were women who were diagnosed with ≥stage II breast cancer, had ≥ one comorbidity and/or persistent treatment-related side-effects, and were insufficiently physically active. Sixty women (50 ± 9 years) were randomized to the low-supervision group (n = 30) or high-supervision group (n = 30). The low-supervision group participated in a 12-week, individually-tailored exercise intervention supported by five supervised sessions with an exercise professional. The high-supervision group participated in the same exercise intervention but received 20 supervised sessions across the 12-week period. The target weekly dosage of 600 metabolic equivalent minutes of exercise per week (MET-mins/wk) and the session content, such as safety and behaviour change topics, were standardized between the groups. The primary outcomes were intervention safety, defined as the number, type, and severity of exercise-related adverse events (e.g., musculoskeletal injury or exacerbated treatment-related side effects), and feasibility, which was defined as compliance to target exercise dosage. The effect of the intervention on quality of life, physical activity, self-efficacy, fitness, and strength was also assessed (pre- and post-intervention, and at 12-week follow-up). The intervention was safe, with no exercise-related adverse events of grade 3 or above in either group. Both groups reported high compliance to the target exercise dosage (median MET-mins/wk: High = 817; Low = 663), suggesting the exercise intervention was feasible, irrespective of supervision level. Improvements in quality of life, physical activity and fitness were observed post-intervention and maintained at follow-up for both groups (p < 0.05). Only the high-supervision group showed clinically-relevant improvements in strength and self-efficacy at post-intervention (p < 0.05). Individually-targeted exercise delivered under high- or low-levels of supervision is safe, feasible and beneficial for women with stage II+ breast cancer. Future research needs to assess whether the greater gains observed in the group who received higher supervision may contribute to longer term maintenance of physical activity levels and overall health benefits. Australian and New Zealand Clinical Trials Registry: ACTRN12616000547448.

Feasibility of Implementing Physical Activity Behavior Change Counseling in an Existing Cancer-Exercise Program

PURPOSE

This study examined the feasibility and acceptability of implementing research-tested physical activity (PA) behavior change counseling (BCC) sessions in an existing cancer-exercise program, and the preliminary effects on cancer survivor's self-efficacy and PA.

METHODS

Participants were cancer survivors undergoing or within six-months of completing cancer treatment(s), and exercise program staff. Cancer survivors were randomized to receive the exercise program plus PABCC, or the standard exercise program. Feasibility and acceptability were assessed by recruitment, adherence, satisfaction, and a focus group with program staff. Qualitative data were analyzed using descriptive thematic analysis. Self-report questionnaires measured PA and exercise self-efficacy.

RESULTS

Recruitment was 33 out of 93 (36.7%), and n = 13 (39%) provided post-program data. Cancer survivors enjoyed PABCC sessions, but reported face-to-face delivery was an added time burden. Program staff expressed desire to implement PABCC, but perceived staff capacity and time as barriers to sustainability. Exercise self-efficacy increased by 21.5% in the PABCC group vs. 4.2% in the control. PA increased by 81.3% in the PABCC group vs. 16.6% in the control group.

CONCLUSIONS

Implementing PABCC in an existing cancer-exercise program was acceptable and promising for increasing moderate to vigorous PA, but additional research is needed to enhance the feasibility and sustainability of translating efficacious behavioral interventions into existing cancer-exercise programs.

Higher Level of Sports Activities Participation during Five-Year Survival Is Associated with Better Quality of Life among Chinese Breast Cancer Survivors

Simple Summary

Engaging in sports activities is strongly encouraged for cancer survivors. We aim to investigate the association between the level of sports activities participation post-diagnosis and quality of life (QoL) among Chinese women with early-stage breast cancer during the first five years of survival. Notably, we confirm in this work that regular participation in sports activities following cancer diagnosis may have a positive effect on patients’ QoL.

Abstract

Evidence about the association between the level of sports activities participation post-diagnosis and quality of life (QoL) among Chinese women with early-stage breast cancer is limited. A validated modified Chinese Baecke questionnaire was used to prospectively measure sports activities among a breast cancer cohort at four time-points: baseline and 18, 36, and 60 months after diagnosis (sports activities during the previous 12 months before each interview); QoL was measured at the same time. In total, 1289, 1125, and 1116 patients were included in the analyses at 18-, 36- and 60-month follow-up, respectively. The percentages of patients who belonged to no (0 metabolic equivalent of task (MET)-hours per week), low-level (<10 MET-hours/week), and high-level (≥10 MET-hours/week) sports activities group were 20.7%, 45.5%, and 33.8% at 18-month follow-up, respectively; the corresponding figures at 36 and 60 months differed slightly. Using data from the three follow-ups, generalized estimating equation (GEE) analyses showed that higher levels of sports activities participation were associated with better QoL in several items as well as fewer symptoms. The present findings in Chinese women with breast cancer provide important evidence on the beneficial effect of regular participation in sports activities following cancer diagnosis on patients’ QoL.

Group-based Exercise Therapy Improves Psychosocial Health and Physical Fitness in Breast Cancer Patients in Hawai'i

Cancer diagnosis and treatment often negatively impact quality of life, worsening prognosis, and long-term survival in cancer patients. Rehabilitation is effective at reversing cancer-related effects, but these services are not standardized. An implementation study was conducted to determine the usability and efficacy of group-based exercise therapy delivered from an outpatient therapy clinic. Thirty breast cancer patients (mean age ± standard deviation [SD],= 55 ± 10 years) completed 36 90-minute group-based exercise sessions in small groups. Team-based exercises were used to foster peer interaction and social support. Usability was evaluated with participant feedback, adherence, and occurrence of adverse events. Effectiveness was measured with the Revised Piper Fatigue, the City of Hope Quality of Life (QOL), and the Beck Depression Inventories. Paired t-tests and 2-way ANOVAs were used to detect significance (P<.05); Cohen's d was used to measure effect size. Twenty-five patients completed the program; they reported that they liked the program design. One anticipated, moderate adverse event occurred. The intervention improved fatigue and QOL, where significant main effects of time were detected [Fatigue: (F(1,76)=29.78, P <.001); QOL: (F(1,80)=24.42, P<.0001)]. Improvements in the fatigue inventory's behavioral/security and sensory dimensions (Cohen's d=-0.43 and ȡ0.68, respectively) and the physical dimension of the QOL inventory were detected (Cohen's d=0.92). There were no significant changes in depression (P=.0735). Seven patients continued to participate in exercise classes for 2.5-years post-intervention, demonstrating achievability of program maintenance. Providing group-based exercise therapy services at an outpatient clinic is an effective and practical approach to improve cancer patients' QOL.

An organizational approach to exploring the determinants of community-based exercise program implementation for breast cancer survivors

BACKGROUND

The majority of breast cancer survivors do not engage in sufficient levels of exercise. Community-based exercise programs (CBEP) may mitigate low rates of exercise participation; however, few programs exist. Previous research exploring the determinants of CBEP implementation for cancer survivors is limited in that it has predominantly focused on cancer survivor perspectives or it has failed to rely on a theoretical framework to explore determinants to implementation across various implementation domains. An organizational exploration of the determinants of CBEP implementation for breast cancer survivors is warranted to guide future program implementation.

PURPOSE

The purpose of this study was to apply the Consolidated Framework for Implementation Research (CFIR) to explore the determinants of CBEP implementation for breast cancer survivors from a program provider perspective.

METHODS

Data collection and analysis were guided by the CFIR. Program providers completed an online questionnaire and an interview. Transcripts were analyzed using inductive content analysis. Resulting codes were deductively mapped onto the CFIR.

RESULTS

Seven barriers and seven facilitators were identified, with three key influencers (e.g., program awareness, financial support, and knowledge regarding the benefits of exercise for breast cancer survivors) cited as both barriers and facilitators to program implementation. Barriers primarily operated within the outer setting (e.g., needs and resources) domain of the CFIR, whereas facilitators and key influencers operated across multiple CFIR domains (e.g., culture and planning).

CONCLUSIONS

Study findings provide insight into the current challenges to CBEP implementation experienced by program providers and highlight potential avenues for future exercise program development and implementation.

Active Living After Cancer: Adaptation and evaluation of a community-based physical activity program for minority and medically underserved breast cancer survivors

Background

An expanding body of research documents the benefits of physical activity for cancer survivors' physical functioning and quality of life, but few successful models provide community‐based physical activity programs to cancer survivors. This report presents an evaluation of Active Living After Cancer, an evidence‐based physical activity program for breast cancer survivors, adapted for community delivery to minority and medically underserved survivors.

Methods

Survivors were recruited from health care and community settings. The program consisted of 12 weekly group sessions providing training in cognitive and behavioral skills for behavior change, brief physical activity, and cancer survivorship‐related content. At the baseline and follow‐up, participants completed assessments of their physical activity, quality of life, and physical functioning (6‐minute walk and 30‐second sit‐to‐stand test). At follow‐up, they also completed questionnaires to measure program content mastery and satisfaction.

Results

The outcome analysis included 127 participants. Physical activity and quality of life (mental and physical) improved from the baseline to follow‐up (all P < .01). Physical functioning improved, with increases in sit‐to‐stand repetitions (mean, 12.5 at the baseline vs 14.9 at the follow‐up; P < .01) and 6‐minute walk distances (mean, 428 m at the baseline vs 470 m at the follow‐up; P < .01).

Conclusions

The results highlight the effectiveness of an evidence‐based program adapted for community‐based delivery to minority and medically underserved breast cancer survivors. The program could be delivered to improve outcomes in diverse survivor populations.

Lay Summary

Physical activity in breast cancer survivors is related to better quality of life and longer cancer‐free survival. However, there are few community‐based programs to help breast cancer survivors to become more physically active.

The Active Living After Cancer program was adapted from an evidence‐based program and delivered in community‐based settings to minority and medically underserved breast cancer survivors. It consisted of 12 weekly group sessions in which participants learned skills to increase their physical activity.

The program participants increased their physical activity and improved their mental and physical well‐being and physical functioning.

The Active Living After Cancer Program has been adapted from an evidence‐based program and implemented in the community for minority and medically underserved breast cancer survivors. Participants increase their physical activity and improve their quality of life and physical functioning.

Evaluation of the Structure and Health Impacts of Exercise-Based Cardiac and Pulmonary Rehabilitation and Prehabilitation for Individuals With Cancer: A Systematic Review and Meta-Analysis

Exercise-based, multimodal rehabilitation programming similar to that used in the existing models of cardiac or pulmonary rehabilitation or prehabilitation is a holistic potential solution to address the range of physical, psychological, and existential (e.g., as their diagnosis relates to potential death) stressors associated with a cancer diagnosis and subsequent treatment. The purpose of this study was to systematically evaluate the structure and format of any type of exercise-based, multimodal rehabilitation programs used in individuals with cancer and the evidence base for their real-world effectiveness on metrics of physical (e.g., cardiorespiratory fitness, blood pressure) and psychological (e.g., health-related quality of life) health. Very few of the 33 included exercise-based, multimodal rehabilitation programs employed intervention components, education topics, and program support staff that were multi-disciplinary or cancer-specific. In particular, a greater emphasis on nutrition care, and the evaluation and management of psychosocial distress and CVD risk factors, with cancer-specific adaptations, would broaden and maximize the holistic health benefits of exercise-based rehabilitation. Despite these opportunities for improvement, exercise-based, multimodal rehabilitation programs utilized under real-world settings in individuals with cancer produced clinically meaningful and large effect sizes for cardiorespiratory fitness (VO2peak, ±2.9 mL/kg/min, 95% CI = 2.6 to 3.3) and 6-minute walk distance (+47 meters, 95% CI = 23 to 71), and medium effect sizes for various measures of cancer-specific, health-related quality of life. However, there were no changes to blood pressure, body mass index, or lung function. Overall, these findings suggest that exercise-based, multimodal rehabilitation is a real-world therapy that improves physical and psychological health among individuals with cancer, but the holistic health benefits of this intervention would likely be enhanced by addressing nutrition, psychosocial concerns, and risk factor management through education and counselling with consideration of the needs of an individual with cancer.

Development of an evidence-informed recommendation guide to facilitate physical activity counseling between oncology care providers and patients in Canada

Decision support aids help reduce decision conflict and are reported as acceptable by patients. Currently, an aid from the American College of Sports Medicine exists to help oncology care providers advise, assess, and refer patients to physical activity (PA). However, some limitations include the lack of specific resources and programs for referral, detailed PA, and physical function assessments and not being designed following an international gold standard (Appraisal of Guidelines for Research and Evaluation [AGREE] II). This study aimed to develop a recommendation guide to facilitate PA counseling by assessing the risk for PA-related adverse events and offering a referral to an appropriate recommendation. Recommendation guide development followed AGREE II, and an AGREE methodologist was consulted. Specifically, a stakeholder group of oncology care providers and cancer survivors were engaged to develop the assessment criteria for comorbidities, PA levels, and physical function. Assessment criteria were developed from published PA interventions, consultations with content experts, and targeted web-based searches for cancer-specific PA programs. Feedback on the recommendation guide was solicited from stakeholders and external reviewers with relevant knowledge and clinical experience. Independent AGREE methodologists appraised the development process. The recommendation guide is a five-page document, including a preamble, assessment criteria for absolute contraindications to PA, comorbidities, and PA/functional capacity with a list of appropriate resources. Independent AGREE methodologists rated the development process as strong and recommended the guide for use. The recommendation guide has the potential to facilitate PA counseling between oncology care providers and cancer survivors, thus, potentially impacting PA behavior.

Effects of a Clinic-Based Exercise Program on Sleep Disturbance Among Cancer Survivors

Introduction

Sleep disturbance is the second leading negative side effect reported by cancer survivors, and evidence exists to suggest that exercise may improve sleep for cancer survivors. This study examined changes in sleep following a 3-month, clinic-based exercise program among a diverse group of cancer survivors.

Methods

Single group, pre-post study design. Participants were enrolled in a supervised exercise program which consisted of moderate intensity aerobic and resistance training, twice per week for 3-months. To be eligible, individuals had to be diagnosed with cancer, and undergoing, or within 6-months of completing chemo and/or radiation therapy. Sleep was assessed at pre-and post-program using 3 self-report questions as part of a standard wellness assessment conducted at the program’s facility. Changes in categorical outcomes were evaluated using McNemar and Wilcoxon Signed-Rank Tests.

Results

Participants (N = 94) were mostly female (68.1%, N = 64), mean age = 54.26 ± 14.26 (20-78), and diagnosed with more than 8 different cancer types. Half (N = 48, 51.1%) of participants improved on 1 or more of the questions assessing sleep. At post-program, 39% of participants reported that they did not awaken feeling rested versus 48% at pre-program (P = .08). At post-program, 47% reported awakening ≥1 time per night versus 46% at pre-program (P = .97), and 17% reported poor or very poor sleep quality at post-program versus 24% at pre-program (P = .16). There were no differences in demographic, cancer-related, psychosocial, and physical fitness variables between participants who improved on any of the questions assessing sleep versus those who did not.

Conclusions

A clinically implemented exercise program may help some cancer survivors improve sleep, however more studies utilizing validated, objective measures of sleep are needed to confirm effectiveness.

Impact of community-based exercise program participation on aerobic capacity in women with and without breast cancer

BACKGROUND

Evidence for exercise as an efficacious strategy to improve aerobic capacity of breast cancer survivors (BCS) has come largely from intervention studies conducted in laboratory settings. There is an increasing need to translate to community-type settings, but the efficacy of those interventions using gold standard evaluation is not well-established.

AIM

To investigate whether similar improvement in aerobic capacity (maximal oxygen consumption [VO₂]) measured with gold standard testing can be achieved through a community-based setting in BCS.

METHODS

A peak cardiopulmonary exercise test (VO_2peak), 6-min walk test (6MWT), and timed up and go test (TUG) were assessed pre- and post-16 wk of progressive intensity aerobic and strength training exercise at a community center.

RESULTS

The sample consisted of 31 early BCS (< 1 year since treatment completion) and 15 controls (CTLs). Both groups significantly improved VO_2peak (+1.2 mL/kg/min; P = 0.030), 6MWT (+35 meters; P < 0.001), and TUG (-0.44 s; P < 0.01) following training. Both groups improved peak cycling power during the cardiopulmonary exercise test with BCS improving by +10 watts more than the CTLs (P = 0.020). Average exercise attendance was 71% (34 of 48 possible days), but compliant days averaged only 60% of total days for aerobic, and < 40% for strength in both groups.

CONCLUSION

Community-based exercise programs can be an effective strategy to improve aerobic capacity and physical function for early-stage BCS but potentially not to the same extent observed in laboratory-based randomized controlled trials. Further research is needed to explore barriers and facilitators of exercise engagement in community-based centers to maximize training benefits for adults with cancer.

Exercise interventions for people diagnosed with cancer: a systematic review of implementation outcomes

PURPOSE

Exercise is efficacious for people living after a cancer diagnosis. However, implementation of exercise interventions in real-world settings is challenging. Implementation outcomes are defined as 'the effects of deliberate and purposive actions to implement new treatments, practices, and services'. Measuring implementation outcomes is a practical way of evaluating implementation success. This systematic review explores the implementation outcomes of exercise interventions evaluated under real-world conditions for cancer care.

METHODS

Using PRISMA guidelines, an electronic database search of Medline, PsycInfo, CINAHL, Web of Science, SportsDiscus, Scopus and Cochrane Central Registry of Controlled Trials was conducted for studies published between January 2000 and February 2020. The Moving through Cancer registry was hand searched. The Implementation Outcomes Framework guided data extraction. Inclusion criteria were adult populations with a cancer diagnosis. Efficacy studies were excluded.

RESULTS

Thirty-seven articles that described 31 unique programs met the inclusion criteria. Implementation outcomes commonly evaluated were feasibility (unique programs n = 17, 54.8%) and adoption (unique programs n = 14, 45.2%). Interventions were typically delivered in the community (unique programs n = 17, 58.6%), in groups (unique programs n = 14, 48.3%) and supervised by a qualified health professional (unique programs n = 14, 48.3%). Implementation outcomes infrequently evaluated were penetration (unique programs n = 1, 3.2%) and sustainability (unique programs n = 1, 3.2%).

CONCLUSIONS

Exercise studies need to measure and evaluate implementation outcomes under real-world conditions. Robust measurement and reporting of implementation outcomes can help to identify what strategies are essential for successful implementation of exercise interventions.

IMPLICATIONS FOR CANCER SURVIVORS

Understanding how exercise interventions can be successful implemented is important so that people living after a cancer diagnosis can derive the benefits of exercise.

Development of the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) algorithm

PURPOSE

Participation in exercise or rehabilitation services is recommended to optimize health, functioning, and well-being across the cancer continuum of care. However, limited knowledge of individual needs and complex decision-making are barriers to connect the right survivor to the right exercise/rehabilitation service at the right time. In this article, we define the levels of exercise/rehabilitation services, provide a conceptual model to improve understanding of individual needs, and describe the development of the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) algorithm.

METHODS

From literature review, we synthesized defining characteristics of exercise/rehabilitation services and individual characteristics associated with safety and efficacy for each service. We developed a visual model to conceptualize the need for each level of specialized care, then organized individual characteristics into a risk-stratified algorithm. Iterative review with a multidisciplinary expert panel was conducted until consensus was reached on algorithm content and format.

RESULTS

We identified eight defining features of the four levels of exercise/rehabilitation services and provide a conceptual model of to guide individualized navigation for each service across the continuum of care. The EXCEEDS algorithm includes a risk-stratified series of eleven dichotomous questions, organized in two sections and ten domains.

CONCLUSIONS

The EXCEEDS algorithm is an evidence-based decision support tool that provides a common language to describe exercise/rehabilitation services, a practical model to understand individualized needs, and step-by-step decision support guidance. The EXCEEDS algorithm is designed to be used at point of care or point of need by multidisciplinary users, including survivors. Thus, implementation may improve care coordination for cancer exercise/rehabilitation services.

Evaluating implementation and pragmatism of cancer-specific exercise programs: a scoping review

PURPOSE

Studies in exercise oncology are increasingly evaluating the implementation of cancer-specific exercise programming in real-world settings. Evaluating current implementation efforts and identifying current research gaps may inform future implementation. This scoping review explores studies implementing cancer-specific exercise programs to determine their pragmatic characteristics and evaluate potential for translation into practice.

METHODS

A systematic literature search was conducted using five databases (up to July 2020) to identify implementation studies that used qualitative or quantitative methods. Program pragmatism was evaluated using the PRECIS/RE-AIM tool.

RESULTS

Fourteen articles were included for review. While programs were moderately pragmatic (average: 3.4; range: 2.8-4.2), variability was observed between scoring domains. Programs scored higher (more pragmatic) in domains typical for effectiveness studies, including participant eligibility, follow-up intensity, primary trial outcome, and analysis of primary outcome. In contrast, programs scored lower (less pragmatic) in domains aligned with implementation science, including intervention flexibility, adoption, implementation, and maintenance. Limited information was reported regarding program fidelity, adaptations, and maintenance/sustainability.

CONCLUSION

Researchers should consider the pragmatism of interventions, the nuances of program adoption and implementation at the setting level, and the transition and integration of programming into the healthcare system. Future studies may benefit from the inclusion of decision-makers and implementation experts and shifting focus towards flexible programming. PRECIS/RE-AIM may facilitate the evaluation of programs throughout the study design and implementation process.

IMPLICATIONS FOR CANCER SURVIVORS

The implementation of pragmatic exercise programs that are both scalable and sustainable is needed so that cancer survivors can experience exercise-related benefits beyond research settings.

Predictors of attendance during an exercise program for cancer survivors

PURPOSE

Exercise programs delivered in community- or clinic-based settings improve physical and psychosocial outcomes among cancer survivors; however, adherence is essential to achieve such benefits. This study examined predictors of attendance to an exercise program in a large, diverse sample of cancer survivors.

METHODS

Participants (n = 302) were enrolled in BfitBwell, an exercise program for adults diagnosed with cancer, and currently receiving or within 6 months of completing chemotherapy or radiation therapy. Participants were offered two supervised aerobic and resistance exercise sessions per week for 3 months. Predictors of attendance included demographics, cancer-related information, quality of life (QOL), fatigue, physical fitness, activity level, and importance of making various changes (e.g., improving fitness). Univariate linear regression first explored associations between predictor variables and adherence, and any important variables (p < .10) were included in a multivariate linear regression model.

RESULTS

Participants were M = 54.9 ± 13.9 years old, mostly female (67.3%), white (83.6%), and most commonly diagnosed with breast cancer (34.8%). Average attendance was 16.2 ± 6.6 exercise sessions. Six-minute walk test distance, QOL, and fatigue were associated with exercise session attendance (p < .05). The multivariable model revealed that higher QOL predicted higher attendance (β = .351, p = .005), and working full- or part-time significantly predicted lower attendance (β =- .221, p =.021).

CONCLUSIONS

Higher pre-program QOL and not working full- or part-time predicted higher exercise program attendance. Existing and future exercise programs for cancer survivors should consider ways to adapt program delivery to provide support to survivors who start with low QOL, and accommodate those who may face barriers to attending due to work schedule/conflict.