Barriers to Supervised Exercise Training in a Randomized Controlled Trial of Breast Cancer Patients Receiving Chemotherapy

Barriers to and facilitators of improving physical activity and nutrition behaviors during chemotherapy for breast cancer: a sequential mixed methods study

PURPOSE

Use qualitative and quantitative methods to explore factors influencing the adoption of guideline-based physical activity (PA) and dietary recommendations among participants enrolled in a lifestyle intervention during and after chemotherapy for breast cancer.

METHODS

Among women with stage I-III breast cancer who participated in the intervention arm of the Lifestyle, Exercise, and Nutrition early after diagnosis (LEANer) trial, we used stratified, purposeful sampling to interview women who met both, one, or neither intervention goal after the 1-year intervention: (1) 150 min/week moderate-to-vigorous intensity exercise via a self-reported PA questionnaire and (2) improved self-reported diet quality measured by the Healthy Eating Index-2015. Semi-structured interviews were audio-recorded, transcribed verbatim, and analyzed using thematic content analysis.

RESULTS

The 29 women interviewed were 52 ± 11 years old on average, with a mean body mass index of 29.6 ± 7.7 kg/m2. Three themes emerged regarding aspects of the LEANer intervention that facilitated behavior change: (1) providing a conduit of trustworthy, timely, and personalized support and education; (2) shifting mindsets and enhanced understanding of the benefits of PA and nutrition during chemotherapy; and (3) fostering a sense of control and alternative focus. Factors described as hindering adoption of goals included: (1) adverse effects of chemotherapy and (2) competing priorities.

CONCLUSIONS

Women reported the external support, tailored education, and experiencing the physical and mental benefits of the LEANer intervention facilitated the adoption of the interventions' behavioral goals. Addressing chemotherapy-related symptoms and competing priorities may facilitate adherence to lifestyle interventions during chemotherapy for breast cancer.

The effectiveness of mind-body therapy and physical training in alleviating depressive symptoms in adult cancer patients: a meta-analysis

PURPOSE

The aim of this study was to assess the effectiveness of mind-body therapy (MBT) and/or physical training in alleviating depressive symptoms among adult cancer patients through a meta-analysis.

METHODS

PubMed, Embase, EBSCO, Web of Science, and Cochrane Library databases were searched from up to October 21, 2023. Effect sizes, 95% confidence intervals, and other pertinent values were computed utilizing a random-effects model with Review Manager 5.3 and StataMP 14. The reporting of findings adhered to the guidelines for systematic reviews and meta-analyses. The PROSPERO registration code for this review is 4,203,477,316.

RESULTS

10 randomized controlled trials (11 datasets) involving a total of 620 participants were selected for analysis. The results demonstrated that complementary therapies, encompassing MBT and physical training, were effective in alleviating depressive symptoms in adult cancer patients (SMD= -0.47; 95%CI: -0.87, -0.08; P = 0.02). Subgroup analysis indicate that physical training may effectively alleviate depressive symptoms (SMD= -0.72; 95%CI: -1.31, -0.13; P = 0.02), demonstrating moderate effect sizes. Conversely, MBT does not seem to significantly influence depressive symptoms (P = 0.69).

CONCLUSIONS

Complementary therapy lasting four weeks or more, incorporating physical training and MBT, has been shown to alleviate depressive symptoms in adult cancer patients. And physical training has a significant effect on depressive symptoms, while MBT has no effect. Nevertheless, given the constraints of the included studies, further research is required in the future to provide more robust evidence.

Feasibility of a novel exercise program for patients with breast cancer offering different modalities and based on patient preference

PURPOSE

Exercise improves quality of life and reduces the side effects of cancer therapies. Nevertheless, attendance to exercise programs remains a challenge for patients. This study explored the feasibility of an exercise program in which women with breast cancer may be allowed to choose among three exercise delivery modalities.

METHODS

Forty-seven patients with breast cancer (stage I-IV) participated in a 12-week combined aerobic and resistance training program. The exercise modality was chosen by patients according to their preferences and needs among three options: the personal training program, the home-based program, or the group-based program. Exercise prescription was similar between the three modalities. Whereas the primary endpoint was feasibility, assessed through recruitment rate, attendance, adherence, dropout rate, tolerability, and safety, secondary endpoints included health-related skills and quality of life.

RESULTS

Out of 47 recruited patients, 24 chose the home-based program, 19 the personal training program, and four the group-based program. Six dropouts (13%) were registered, and no severe adverse events were recorded. The median program attendance was 98% for personal training programs, 96% for home-based programs, and 100% for group-based programs, whereas compliance resulted in more than 90% in each modality. At postintervention, a significant increase in cardiorespiratory fitness, lower body flexibility, and body weight was observed. Different quality-of-life domains were improved following the intervention, including physical and social functioning, fatigue, and appetite loss. No significant changes in other parameters were detected.

CONCLUSIONS

An exercise prescription based on a patient-preferred delivery modality showed high feasibility in women with breast cancer.

Patterns and influencing factors of exercise attendance of breast cancer patients during neoadjuvant chemotherapy

BACKGROUND

Performing 2-3 exercise sessions/week may relieve therapy-related side effects of breast cancer patients (BRCA) and improve their quality of life. However, attendance to the exercise sessions is often impaired. Thus, we investigated patterns and possible influencing factors of attendance to an aerobic (AT) or resistance training (RT) intervention in BRCA during neoadjuvant chemotherapy.

METHODS

BRCA (N = 122) were randomly allocated to supervised AT or RT twice weekly during neoadjuvant chemotherapy (18 ± 4 weeks). Attendance was calculated individually and group-wise per training week as the percentage of the performed sessions out of the prescribed sessions. Possible influencing factors were investigated using multiple regression analyses.

RESULTS

Mean individual attendance was 44.1% ± 29.3% with no significant differences between the groups. Group-wise attendance was highest in the first 6 weeks of training with ≥ 60% for AT and ≥ 50% for RT, but decreased over the course of the intervention accompanying chemotherapy. Significantly higher attendance was associated with not having vs. having nausea (ß =  - 14.57; p = 0.007) and not having vs. having pain (ß =  - 12.07; p = 0.12), whereas fatigue did not show any association (ß =  - 0.006; p = 0.96). Having been randomized into a preferred intervention group (48.8%) showed no association with attendance. Yet, patients' rating of the exercise intervention as "good"/ "very good" (58.7%) was significantly associated with higher attendance (p = 0.01).

CONCLUSION

For both exercise interventions, group-wise attendance/training week decreased during chemotherapy despite good intervention ratings. While some patients never started, others trained almost constantly twice weekly. The study revealed that patients who are nauseous or experience pain may need more support to attend more exercise sessions. Trial Registration Clinicaltrials.gov: NCT02999074 from May 6, 2016.

The "home-based exercise for breast and prostate cancer patients during treatment-a feasibility trial" (BENEFIT CA trial): rationale and methodological protocol

BACKGROUND

Physical activity has been shown to benefit patients undergoing adjuvant cancer therapy. Although exercise interventions may be applied in several settings, most trials have focused on specialized facilities for their interventions. While these approaches benefit the access for individuals living near exercise centers, it hampers the assessment of real-world effectiveness. Therefore, evaluating the feasibility and implementation of home-based models of exercise training, especially in low-to-middle-income settings, may inform future physical activity trials and programs. In this article, we present the protocol for the BENEFIT CA trial, which aims to assess the implementation of a remote exercise intervention for patients with breast cancer or prostate cancer, primarily quantifying adherence to an exercise program.

METHODS

This is a 12-week study, utilizing a non-randomized, single-arm design to assess the feasibility of a home-based exercise training. The intervention is remotely guided, and participants also receive an educational component about cancer and exercise. The study aims to recruit 40 patients diagnosed with breast cancer and 40 patients diagnosed with prostate cancer, all of whom undergoing active hormonal treatment. The primary outcome is the level of adherence, indicated as the proportion of performed exercise episodes. Secondary outcomes include recruitment rates, fatigue, quality of life, and functional capacity. Adverse events will be monitored throughout the study. Because this is a feasibility trial, the statistical analysis plan is based on descriptive statistics, which encompasses an intention-to-treat analysis and a plan for handling missing data.

DISCUSSION

This is a low-cost feasibility study to orient the design of a wide-range, pragmatic phase 3 trial based on remote exercise intervention. With this study, we aim to better understand the adherence and implementation strategies regarding home-based exercise for the proposed population and, in the near future, move forward to a randomized clinical trial. In addition, this trial may contribute to engage patients with cancer in exercise programs throughout their treatment and beyond.

TRIAL REGISTRATION

This trial has been approved by the Hospital de Clínicas de Porto Alegre Ethics Committee/IRB (48,869,621.9.0000.5327), and it is registered at Clinicaltrials.gov (NCT05258526), registered on February 25, 2022, prior to the beginning of the study.

A systematic review of behavioural and exercise interventions for the prevention and management of chemotherapy-induced peripheral neuropathy symptoms

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) can result in functional difficulties. Pharmacological interventions used to prevent CIPN either show low efficacy or lack evidence to support their use and to date, duloxetine remains the only recommended treatment for painful CIPN. Non-pharmacological interventions such as exercise and behavioural interventions for CIPN exist.

PURPOSE

The aims were to (1) identify and appraise evidence on existing behavioural and exercise interventions focussed on preventing or managing CIPN symptoms, (2) describe psychological mechanisms of action by which interventions influenced CIPN symptoms, (3) determine the underpinning conceptual models that describe how an intervention may create behaviour change, (4) identify treatment components of each intervention and contextual factors, (5) determine the nature and extent of patient and clinician involvement in developing existing interventions and (6) summarise the relative efficacy or effectiveness of interventions to lessen CIPN symptoms and to improve quality of life, balance and muscle strength.

METHODS

A systematic search of Ovid Medline, Cochrane Library, EMBASE, PsycINFO, Health Management Information Consortium, Global Health and CINAHL was performed to identify articles published between January 2000 to May 2020, followed by OpenGrey search and hand-searching of relevant journals. Studies that explored behavioural and/or exercise interventions designed to prevent or improve symptoms of CIPN in adults who had received or were receiving neurotoxic chemotherapy for any type of cancer, irrespective of when delivered within the cancer pathway were included.

RESULTS

Nineteen randomised controlled trials and quasi-experimental studies which explored behavioural (n=6) and exercise (n=13) interventions were included. Four studies were rated as methodologically strong, ten were moderate and five were weak. Ten exercise and two behavioural interventions, including those that improved CIPN knowledge and self-management resources and facilitated symptom self-reporting, led to reduced CIPN symptoms during and/or after chemotherapy treatment.

CONCLUSIONS

The extent of potential benefits from the interventions was difficult to judge, due to study limitations. Future interventions should incorporate a clear theoretical framework and involve patients and clinicians in the development process.

IMPLICATIONS FOR CANCER SURVIVORS

Our findings show exercise interventions have beneficial effects on CIPN symptoms although higher quality research is warranted. Behavioural interventions that increase patient's CIPN knowledge, improve self-management capacity and enable timely access to symptom management led to reduced CIPN symptoms.

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.

Effects of supervised high-intensity interval training on motivational outcomes in men with prostate cancer undergoing active surveillance: results from a randomized controlled trial

Background

Understanding the motivational effects of supervised aerobic high-intensity interval training (HIIT) may help men with prostate cancer undergoing active surveillance initiate and maintain exercise behavior, however, few studies have addressed this question. This report explored exercise motivation in men with prostate cancer undergoing active surveillance participating in a randomized exercise trial.

Methods

The Exercise during Active Surveillance for Prostate Cancer (ERASE) trial randomized 52 men with prostate cancer on active surveillance to the HIIT exercise group or the usual care (UC) group. The exercise program was supervised aerobic HIIT conducted three times per week for 12 weeks. The motivation questions were developed using the Theory of Planned Behavior and included motivational constructs, anticipated and experienced outcomes, and barriers to HIIT during active surveillance.

Results

The HIIT group attended 96% of the planned exercise sessions with 100% compliance to the exercise protocol. Motivation outcome data were obtained in 25/26 (96%) participants in the HIIT group and 25/26 (96%) participants in the UC group. At baseline, study participants were generally motivated to perform HIIT. After the intervention, the HIIT group reported that HIIT was even more enjoyable (p < 0.001; d = 1.38), more motivating (p = 0.001; d = 0.89), more controllable (p < 0.001; d = 0.85), and instilled more confidence (p = 0.004; d = 0.66) than they had anticipated. Moreover, compared to UC, HIIT participants reported significantly higher perceived control (p = 0.006; d = 0.68) and a more specific plan (p = 0.032; d = 0.67) for performing HIIT over the next 6 months. No significant differences were found in anticipated versus experienced outcomes. Exercise barriers were minimal, however, the most often reported barriers included pain or soreness (56%), traveling to the fitness center (40%), and being too busy and having limited time (36%).

Conclusion

Men with prostate cancer on active surveillance were largely motivated and expected significant benefits from a supervised HIIT program. Moreover, the men assigned to the HIIT program experienced few barriers and achieved high adherence, which further improved their motivation. Future research is needed to understand long-term exercise motivation and behavior change in this setting.

Trial registration

Clinicaltrials.gov, NCT03203460. Registered on June 29, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01365-2.

Low-frequency exercise training improves cardiovascular fitness and strength during treatment for breast cancer: a single-arm intervention study

Aerobic and resistance exercise during and after cancer treatment are important for health-related outcomes, however treatment-specific barriers may inhibit adherence. We explored the effect of lower-frequency exercise training on fitness, body composition, and metabolic markers (i.e. glucose and lipids) in a group of recently diagnosed breast cancer patients. Fifty-two females ≥ 18 years with stage I-IIIB breast cancer were instructed to attend 2 cardiovascular and strength training sessions/week over 12 weeks, but program length was expanded as needed to accommodate missed sessions. Pre- and post-intervention, we measured: (1) cardiovascular fitness, (2) isometric strength, (3) body composition (dual-energy X-ray absorptiometry), and (4) fasting glucose, insulin, c-peptide, and lipids. Pre-intervention, participants were 53 ± 10 years old (mean ± SD) and overweight (BMI: 27.5 ± 5.4 kg m^-2, 40.1 ± 6.5% body fat). Forty participants completed the program over a median 20 weeks (range: 13-32 weeks, median frequency: 1.2 sessions/week), over which predicted VO₂peak improved by 7% (2.2[0.1-4.4] mL/kg/min) (delta[95% CI]), and strength increased by 7-9% (right arm: 2.3[0.1-4.5] N m; right leg: 7.9[2.1-13.7] N m; left leg: 7.8[1.9-13.7] N m). Body composition and metabolic markers were unchanged. An exercise frequency of 1.2 sessions/week stimulated significant improvements in fitness, and may represent a practical target for patients during active treatment.

Exercise Adherence and Effect of Self-Regulatory Behavior Change Techniques in Patients Undergoing Curative Cancer Treatment: Secondary Analysis from the Phys-Can Randomized Controlled Trial

INTRODUCTION

Adherence to exercise interventions in patients with cancer is often poorly described. Further, it is unclear if self-regulatory behavior change techniques (BCTs) can improve exercise adherence in cancer populations. We aimed to (1) describe exercise adherence in terms of frequency, intensity, time, type (FITT-principles) and dropouts, and (2) determine the effect of specific self-regulatory BCTs on exercise adherence in patients participating in an exercise intervention during curative cancer treatment.

METHODS

This study was a secondary analysis using data from a Swedish multicentre RCT. In a 2×2 factorial design, 577 participants recently diagnosed with curable breast, colorectal or prostate cancer were randomized to 6 months of high (HI) or low-to-moderate intensity (LMI) exercise, with or without self-regulatory BCTs (e.g., goal-setting and self-monitoring). The exercise program included supervised group-based resistance training and home-based endurance training. Exercise adherence (performed training/prescribed training) was assessed using attendance records, training logs and heart rate monitors, and is presented descriptively. Linear regression and logistic regression were used to assess the effect of self-regulatory BCTs on each FITT-principle and dropout rates, according to intention-to-treat.

RESULTS

For resistance training (groups with vs without self-regulatory BCTs), participants attended on average 52% vs 53% of prescribed sessions, performed 79% vs 76% of prescribed intensity, and 80% vs 77% of prescribed time. They adhered to exercise type in 71% vs 68% of attended sessions. For endurance training (groups with vs without self-regulatory BCTs), participants performed on average 47% vs 51% of prescribed sessions, 57% vs 62% of prescribed intensity, and 71% vs 72% of prescribed time. They adhered to exercise type in 79% vs 78% of performed sessions. Dropout rates (groups with vs without self-regulatory BCTs) were 29% vs 28%. The regression analysis revealed no effect of the self-regulatory BCTs on exercise adherence.

CONCLUSION

An exercise adherence rate ≥50% for each FITT-principle and dropout rates at ~30% can be expected among patients taking part in long-term exercise interventions, combining resistance and endurance training during curative cancer treatment. Our results indicate that self-regulatory BCTs do not improve exercise adherence in interventions that provide evidence-based support to all participants (e.g., supervised group sessions).

TRIAL REGISTRATION

NCT02473003.

Anamorelin combined with physical activity, and nutritional counseling for cancer-related fatigue: a preliminary study

PURPOSE

Cancer-related fatigue (CRF) is the most frequent and debilitating symptom in patients with advanced cancer. There are limited effective treatments for CRF. The objective of this prospective longitudinal study was to evaluate the change in CRF at Day 43 after treatment with combination therapy of oral Anamorelin 100 mg daily with physical activity and nutrition counseling.

METHODS

In this study, patients with CRF [≤ 34 Functional Assessment of Chronic Illness Therapy-Fatigue subscales(FACIT-F)] received Anamorelin 100 mg orally daily with standardized physical activity and nutrition counseling for 43 days. Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Anorexia Cachexia(FAACT-ACS), Multidimensional Fatigue Symptom Inventory-Short Form(MFSI-SF), Patient-Reported Outcomes Measurement Information System(PROMIS-Fatigue), body composition, and physical performance tests were assessed at baseline, Day 15, 29, and 43. Frequency and type of side effects were determined by NCI CTAE 4.0.(NCT03035409).

RESULTS

28/45 (62%) of patients dosed were evaluable at Day 43. The mean, SD for FACIT-F subscale improvement from baseline was 4.89 (± 13.07), P = .058, MFSI-SF (G) - 3.46 (± 6.86), P = 0.013, PROMIS-fatigue - 4.14 (± 7.88), P = 0.010, FAACT ACS 3.48 (± 8.13), P = 0.035. Godin Liesure-Time physical activity questionnaire 7.41 (± 16.50), P = 0.038. Weight (kg) 1.81 (± 2.63), P = 0.005, and Lean Body Mass 1.54 (± 1.85), P = 0.001, IGF-1 36.50 (± 48.76), P = 0.015. There was no significant improvement in physical performance outcomes. No adverse events > grade 3 related to the study drug were reported.

CONCLUSION

The use of the combination therapy was associated with improvement of CRF (FACIT-F fatigue, PROMIS-fatigue, MFSI-SF-general), activity (Godin-leisure time), anorexia (FAACT), body composition, and IGF-1 levels. Further studies using combination therapy for CRF are justified.

Factors influencing physical activity participation among people living with or beyond cancer: a systematic scoping review

BACKGROUND

It has been posited that physical activity (PA) has the potential to improve health outcomes and the health-related quality of life of people living with or beyond cancer. Despite the well-documented health benefits of PA, there is a low level of PA among cancer patients. A systematic scoping review was conducted to investigate attitudes, perceptions, preferences and barriers vs. facilitators to cancer patients' PA participation.

METHODS

A systematic search was performed across four automated databases (PubMed, Embase, PsycINFO and Medline) in keeping with the PRISMA guideline. All cancer types were included, and any age/gender groups were eligible. Both qualitative and quantitative studies were included. The Health Belief Model provided a conceptual framework for the conduct of the scoping review as well as guiding thinking to inform evidence-based interventions.

RESULTS

Ninety-eight articles were included in this review. Nearly half of the studies focused on mixed cancer sites; breast cancer was the most commonly examined cancer type (19%). Post-treatment was the most commonly investigated stage (33%), followed by studies of mixed stages of the cancer trajectory (27%), the acute treatment stage (23%) and pre-treatment stage (1%). Patient treatment stage was not reported in 16% of studies. Cancer patients reported positive attitudes to PA and recognized its benefits for health and wellbeing. Cancer-related side effects (e.g. fatigue) were a leading physiological barrier to PA participation, whereas effective symptom management techniques/tools acted as a powerful facilitator. Psychosocial barriers included low motivation and kinesiophobia, and perceived health benefits and social support/guidance by healthcare providers were significant facilitators. Inaccessible fitness facilities hindered cancer patients' PA engagement though the availability of tailored amenities appeared to be a strong facilitator. PA preferences varied in terms of type, place, time, company and source of information and pointed to the need for individualized PA programs.

CONCLUSIONS

There is a need for further research to identify barriers and facilitators to PA that are faced by patients with particular cancer types. Recommended PA promoting-strategies involve including exercise science professionals in healthcare teams and ensuring that fitness facilities are accessible.

Exercise efficacy and prescription during treatment for pancreatic ductal adenocarcinoma: a systematic review

BACKGROUND

Surgical resection remains the only curative treatment for pancreatic cancer and is associated with significant post-operative morbidity and mortality. Patients eligible for surgery, increasingly receive neo-adjuvant therapy before surgery or adjuvant therapy afterward, inherently exposing them to toxicity. As such, optimizing physical function through exercise during treatment remains imperative to optimize quality of life either before surgery or during rehabilitation. However, current exercise efficacy and prescription in pancreatic cancer is unknown. Therefore, this study aims to summarise the published literature on exercise studies conducted in patients with pancreatic cancer undergoing treatment with a focus on determining the current prescription and progression patterns being used in this population.

METHODS

A systematic review of four databases identified studies evaluating the effects of exercise on aerobic fitness, muscle strength, physical function, body composition, fatigue and quality of life in participants with pancreatic cancer undergoing treatment, published up to 24 July 2020. Two reviewers independently reviewed and appraised the methodological quality of each study.

RESULTS

Twelve studies with a total of 300 participants were included. Heterogeneity of the literature prevented meta-analysis. Exercise was associated with improvements in outcomes; however, study quality was variable with the majority of studies receiving a weak rating.

CONCLUSIONS

High quality evidence regarding the efficacy and prescription of exercise in pancreatic cancer is lacking. Well-designed trials, which have received feedback and input from key stakeholders prior to implementation, are required to examine the impact of exercise in pancreatic cancer on key cancer related health outcomes.

Cancer Patients' Long-term Experiences of Participating in a Comprehensive Lifestyle Intervention Study While Receiving Chemotherapy

BACKGROUND

Lifestyle interventions seem promising with regard to cancer patients' potential for physical and psychological health benefits and as an empowerment tool. Nevertheless, there is a lack of knowledge concerning cancer patients' longer-term experiences of participating in comprehensive lifestyle interventions.

OBJECTIVE

The aim of this study was to explore cancer patients' long-term experiences of participating in a 12-month individualized comprehensive lifestyle intervention study focusing on physical activity, diet, smoking cessation, and stress management while receiving curative or palliative chemotherapy.

METHODS

A qualitative design with semistructured interviews of 7 curative and 7 palliative cancer patients was conducted 12 months after inclusion in lifestyle intervention. Data were analyzed following a phenomenological-hermeneutic approach.

RESULTS

Two main themes emerged: (1) awareness of the importance of a healthy lifestyle during cancer treatment and (2) individual follow-up; it's good to have someone to talk to.

CONCLUSIONS

Participation in a 12-month comprehensive lifestyle intervention is both feasible and desirable in curative and palliative patients. However, although the curative participants' motivation and perceived ability to adhere to lifestyle recommendations increased during the intervention period, the palliative participants' perceived ability to adhere decreased even though they were overall highly motivated.

IMPLICATIONS FOR PRACTICE

Our findings encourage the future implementation of lifestyle interventions during cancer treatment, even in cancer patients with advanced disease. However, when implementing lifestyle interventions, healthcare professionals must keep the patients' motivation, perceived ability to adhere to lifestyle recommendations, and individual needs in mind.

Exercise Levels and Preferences in Cancer Patients: A Cross-Sectional Study

BACKGROUND

Despite the benefits related to physical exercise, large numbers of cancer patients are not sufficiently active.

METHODS

To investigate exercise levels and preferences in cancer patients, a cross-sectional study was conducted on a random sample of 392 cancer outpatients who anonymously completed a questionnaire investigating general and medical characteristics, and expressed willingness to participate in exercise programs. Current exercise levels were estimated with the Leisure Score Index (LSI).

RESULTS

Most patients (93%) were insufficiently active but 80% declared an interest in exercise programs. Patients preferred oncologist-instructed programs and specified particular exercise needs. Multivariate logistic regression showed that willingness to exercise was associated with education (OR: 1.87; 95% CI: 1.15-3.04 beyond age 14 years vs. up to 14 years) and current physical activity (OR: 1.92; 95% CI: 1.92-3.63 for sweat-inducing activity >2 times/week vs. <1 time/week). Patients given chemotherapy were less inclined to exercise (OR: 0.45; 95% CI: 0.23-0.86) than those who did not. LSI was lower if cancer stage was advanced (β: -0.36; 95% CI: -0.75 to -0.02) than if it was in remission. High LSI was also associated with longer education, lower BMI, and longer time after diagnosis.

CONCLUSION

Cancer patients are insufficiently active but are willing to participate in personalized exercise programs. Information from this survey may help in designing personalized interventions so these patients will achieve sufficient exercise.

Predictors of Adherence to Different Volumes of Exercise in the Breast Cancer and Exercise Trial in Alberta

BACKGROUND

Exercise demonstrates a dose-response effect on many health outcomes; however, adhering to higher doses of exercise can be challenging, and the predictors of adherence may differ based on exercise volume.

PURPOSE

To examine the predictors of adherence to two different volumes of aerobic exercise within the Breast Cancer and Exercise Trial in Alberta (BETA).

METHODS

In BETA, we randomized 400 inactive but healthy postmenopausal women to either a moderate volume (150 min/week) or a high volume (300 min/week) of aerobic exercise for 1 year. We collected data on several predictors of exercise adherence at baseline and used linear and mixed-effect models to determine predictors of exercise adherence to exercise volume and overall.

RESULTS

Adherence was higher in the moderate-volume group (84.5%) compared with the high-volume group (75.2%; p < .001). There were no statistically significant interactions between predictors of exercise adherence and exercise volume. Overall, we found that exercise adherence was predicted by randomization group, body mass index (BMI), employment status, and physical health. Adherence was 8.6% lower in the high-volume versus moderate-volume group, 6.7% lower for women working full time versus not, 0.8% lower per BMI increase of 1 kg/m2, and 0.5% higher per unit of physical health.

CONCLUSIONS

Adherence to high-volume aerobic exercise was more challenging than for moderate-volume aerobic exercise, but the predictors of adherence were similar. Moreover, few factors were major predictors of exercise adherence in this setting suggesting that well-controlled efficacy trials that produce high adherence rates may reduce the influence of individual characteristics on exercise adherence.

TRIAL REGISTRATION

NCT1435005.

Barriers to physical activity participation in colorectal cancer patients during chemotherapy treatment: A qualitative study

PURPOSE

To explore the barriers that colorectal cancer patients (stage II and III) perceive to participate in physical activity (PA) when involved in adjuvant chemotherapy. Views of relatives and physicians concerning this issue were also included.

METHOD

Qualitative data from ten patients, ten relatives, and ten health professionals were obtained through semi-structured interviews (n = 30).

RESULTS

Two main themes were identified after data analysis: (a) barriers to PA related to ostomy and adjuvant chemotherapy and (b) barriers related to perceived lack of support for PA. In regard to the first theme, participants reported difficulties associated with the ostomy, limitations of the intravenous chemotherapy device, fatigue and reduced physical fitness, and focusing on cancer and restructuring priorities. Concerning the perceived lack of support for PA, participants referred to their families' overprotection, the health professionals' lack of knowledge and time to prescribe PA, and the lack of PA services in health centres.

CONCLUSIONS

Further information from health professionals about the recommendations of PA and its benefits during adjuvant chemotherapy could palliate these PA barriers. The offer of specific PA programmes for these patients is also recommended.

The impact of breast cancer on physical activity from midlife to early older adulthood and predictors of change post-diagnosis

PURPOSE

To examine physical activity (PA) patterns from pre- to post-diagnosis, and compare these changes to women without breast cancer. To determine pre-diagnosis predictors of PA change, post-diagnosis, in breast cancer survivors (BCS).

METHODS

Data were from 2314 Study of Women's Health Across the Nation (SWAN) participants, average age of 46.4 ± 2.7 years at baseline (1996-1997). In Pink SWAN, 151 women who reported an incident breast cancer diagnosis over 20 years were classified as BCS; the remaining 2163 women were controls. LOESS plots and linear mixed models were used to illustrate and compare PA changes (sports/exercise [primary measure] and total PA) from pre- to post-diagnosis (or corresponding period) in BCS versus controls. Adjusted linear regression models were used to determine pre-diagnosis predictors of at-risk post-diagnosis PA change patterns (consistently low and decreased PA).

RESULTS

No differences in pre- to post-diagnosis PA (or corresponding period) were observed in BCS versus controls. Among BCS, the odds of at-risk post-diagnosis PA change patterns was 2.50 (95% CI 0.96-6.48) times higher for those who reported sleep problems at ≥ 50% (compared to 0%) of pre-diagnosis visits and 3.49 (95% CI 1.26-9.65) times higher for those who were overweight or obese at all (compared to no) pre-diagnosis visits. No other statistically significant predictors were noted.

CONCLUSIONS

Age-related declines in PA were not amplified by a breast cancer diagnosis. Given the beneficial role of PA across the cancer control continuum, efforts to increase or maintain adequate PA, post-diagnosis, should be continued.

IMPLICATIONS FOR CANCER SURVIVORS

While age-related physical activity declines were not amplified breast cancer diagnosis, efforts to identify breast cancer survivors at increased risk for post-diagnosis physical activity declines (or maintenance of low activity) may be a high-yield strategy to improve prognosis and quality of life.

The Role and Scope of Prehabilitation in Cancer Care

OBJECTIVES

To recognize cancer prehabilitation as a pretreatment regimen to increase functional status for patients requiring cancer treatment. This article presents current evidence addressing the efficacy and benefits of prehabilitation regimens in different cancer survivor populations.

DATA SOURCES

Studies and case reports in the PubMed database.

CONCLUSION

Cancer prehabilitation may improve outcomes. Prehabilitation may include targeted or whole-body exercise, nutrition, education, psychologic counseling, and smoking cessation. Opportunities exist to further improve access to and delivery of multimodal prehabilitation, and nurses play a critical role in connecting patients to these services.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses who are knowledgeable of cancer treatment-related effects are poised to assess survivors for existing impairments, advocate for prehabilitation for existing and potential morbidities, and monitor functional status over time. As patient educators, they are key to informing cancer survivors about the role of prehabilitation.

Exercise Behaviors and Fatigue in Patients Receiving Immunotherapy for Advanced Melanoma: A Cross-Sectional Survey via Social Media

Objective: Treatment with immunotherapy has positively changed the long-term outlook of many patients with advanced melanoma; however, fatigue is a common and debilitating side effect. Evidence indicates exercise can improve treatment-related fatigue for patients receiving chemotherapy and radiotherapy. However, currently little is known about exercise behaviors and preferences of patients receiving immunotherapy. This project aimed to describe self-reported levels of fatigue related to immunotherapy; patient perspectives of exercise behaviors; and barriers and facilitators to engagement in exercise for patients receiving, or recently completed immunotherapy for unresectable stage III and stage IV melanoma. Method: A cross-sectional purpose-built survey was distributed to members of the Melanoma Patients Australia closed Facebook group via an online survey platform. The survey remained active for 1 month, with 3 posts during this time inviting members to participate. Results: A total of 55 responses were collected. Just over half the participants (n = 31; 56%) described exercising while receiving immunotherapy, with walking as the most common activity (n = 24; 77%). Participants described a range of physical and emotional benefits of exercise, the most predominant being fatigue reduction. Barriers to exercise also included fatigue and competing physical demands at home or work. Patient understanding of what constitutes exercise appeared to differ from clinical classifications. Conclusions: Results from this study indicate that patients are engaging in exercise while receiving immunotherapy, with the intent of mediating treatment-related fatigue. Identification of preferred exercise activities and barriers will assist in developing tailored exercise interventions for this cohort.

A mixed-methods evaluation of a community physical activity program for breast cancer survivors

Background

Given the benefits of physical activity for health and survival, clinicians are seeking opportunities for cancer patients to become more active independent of rehabilitation programs that are small, time-limited, and location specific. This proof-of-concept study evaluated a community-based physical activity program (Curves™) for increasing physical activity among women diagnosed and treated for breast cancer.

Methods

Women were recruited from a breast cancer clinic through physician chart review. In study 1, women (n = 14) received the community physical activity memberships (Curves™), guidelines, and a pedometer. This group was compared to women (n = 16) who received physical activity guidelines and a pedometer on changes in physical activity. In study 2, women (n = 66) completed self-report questionnaires after Curves™ memberships expired to evaluate the program. Study 3 was a qualitative study exploring the benefits and barriers of the physical activity program among women (n = 6) who attended Curves™ regularly.

Results

Provision of memberships to a community-based physical activity program did not improve physical activity levels beyond educational and information resources. However, there are a number of advantages to community-based physical activity programs, and the women offer a number of suggestions for improvements for community physical activity opportunities aimed at breast cancer survivors.

Conclusions

Women-only community-based physical activity programs may be a viable option to help introduce women to get active after treatment.

Trial registration ISRCTN, ISRCTN14747810. Registered on 18 October 2017—Retrospectively registered, 10.1186/ISRCTN14747810

Experiences of Patients With Breast Cancer of Participating in a Lifestyle Intervention Study While Receiving Adjuvant Chemotherapy

BACKGROUND

Lifestyle interventions are suggested to reduce the symptom burden and comorbidities in patients with breast cancer and as an empowerment tool. However, undergoing chemotherapy is associated with low compliance to lifestyle recommendations. Importantly, few studies have documented the experiences of patients with breast cancer of participating in a comprehensive lifestyle intervention study while undergoing curative chemotherapy.

OBJECTIVE

The aim of this study was to explore the experiences of patients with breast cancer of participating in an individualized comprehensive lifestyle intervention study focusing on diet, physical activity, mental stress management, and smoking cessation while undergoing curative chemotherapy.

METHODS

A qualitative design with semistructured interviews of 10 patients with breast cancer undergoing curative chemotherapy was conducted 3 to 4 months after inclusion to the lifestyle intervention. Interviews were transcribed verbatim, and qualitative content analysis with a hermeneutic perspective was applied.

RESULTS

Two main themes emerged: (1) breast cancer treatment may put motivation for lifestyle changes on hold, and (2) individualization is the key.

CONCLUSIONS

Participating in a lifestyle intervention may impose additional burdens on patients with cancer undergoing adjuvant chemotherapy. Despite this, most women experienced participation as beneficial, and importantly, all would recommend that patients in the same situation should participate.

IMPLICATIONS FOR PRACTICE

Healthcare professionals should have the patients' individual needs in mind when implementing lifestyle interventions, and the timing of lifestyle interventions should be implemented thoughtfully in patients with breast cancer undergoing chemotherapy in an adjuvant setting. Furthermore, the participants' experiences described here are valuable for the design of future lifestyle intervention studies.

Exercise interventions for patients with advanced cancer: A systematic review of recruitment, attrition, and exercise adherence rates

Purpose

Patients with advanced cancer can experience debilitating physical symptoms, making participation in exercise programs difficult. This systematic review investigated the recruitment, adherence, and attrition rates of patients with advanced cancer participating in exercise interventions and examined components of exercise programs that may affect these rates.

Methods

Relevant studies were identified in a systematic search of CINAHL, PubMed, PsycINFO, and EMBASE to December 2017. Two quality assessment tools were used, and levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine (CEBM) guidelines.

Results

The search identified 18 studies published between 2004 and 2017. Recruitment, adherence, and attrition rates varied widely among the studies reviewed. The mean recruitment rate was 49% (standard deviation [SD] = 17; range 15–74%). Patient-reported barriers to recruitment included time constraints and difficulties in traveling to exercise centers. Levels of adherence ranged from 44% to 95%; however, the definition of adherence varied substantially among trials. The average attrition rate was 24% (SD = 8; range 10–42%), with progression of disease status reported as the main cause for dropout during exercise interventions.

Significance of results

Concentrated efforts are needed to increase the numbers of patients with advanced disease recruited to exercise programs. Broadening the eligibility criteria for exercise interventions may improve accrual numbers of patients with advanced cancer to exercise trials and ensure patients recruited are representative of clinical practice.

Attendance and compliance with an exercise program during localized breast cancer treatment in a randomized controlled trial: The PACT study

PURPOSE

Maintaining high adherence rates (session attendance and compliance) in exercise programs during breast cancer treatment can be challenging. We aimed to identify adherence rates and predictors to an exercise program during adjuvant breast cancer treatment.

METHODS

Ninety-two patients with localized breast cancer undergoing chemotherapy were randomly assigned to an 18-week supervised moderate-to-high intensity aerobic and resistance exercise program, including two 1-hour sessions/week. Additionally, participants were asked to be physically active for at least 30 minutes/day on at least three other days. We report median percentages for attendance, compliance with the prescribed duration and intensity of aerobic and muscle strength exercises, and the exercise advice given. Predictors included in univariate and multivariable linear regression models were demographical, tumor- and treatment-related factors, constructs of the theory of planned behavior, psychological and physical factors.

RESULTS

Patients attended 83% (interquartile range: 69-91%) of the supervised sessions. Compliance with the duration of aerobic exercise, high-intensity aerobic exercise (cycling at the ventilatory threshold), muscle strength exercises and the exercise advice were 88%(64-97%), 50%(22-82%), 84%(65-94%) and 61%(33%-79%), respectively. Education, radiotherapy, BMI and physical fatigue were important predictors of adherence to supervised exercise. Beliefs about planned behaviors were important predictors, especially for compliance with the exercise advice.

CONCLUSIONS

Attendance to and compliance with an 18-week aerobic and strength exercise program were high. The lowest compliance was found for high-intensity supervised aerobic exercise. The identified predictors should be considered when designing or adapting exercise programs for patients with localized breast cancer to increase adherence.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN43801571 Dutch Trial Register NTR2138.

Adherence to a long-term progressive resistance training program, combining supervised and home-based exercise for breast cancer patients during adjuvant treatment

Background: The purpose of the study was to examine adherence and identify patient- and treatment-related factors associated with adherence to a 20-week combined supervised and home-based progressive resistance training program in women treated for breast cancer. Methodology: The study population consisted of the intervention group in a randomized clinical trial examining the effect of resistance exercise on lymphoedema prevention (n = 82). The full program lasted 50 weeks, with an initial 20 weeks combined supervised and home-based exercise followed by 30 weeks self-administered exercise. Information about attendance rates (supervised exercise) and exercise dairies (home-based exercise) in the first 20 weeks was available for 74 and 62 participants, respectively. Adherence was measured as numbers of exercise sessions performed divided by expected number of exercise sessions with >2/3 categorized as high adherence. Age-adjusted odds ratios (OR) were used to assess the associations between patient- and treatment-related factors with adherence. Results: The number of participants with high adherence to supervised exercise decreased in the late period (from week 11 onward) compared to the early period (65% vs. 48%) whereas the proportion of participants with high adherence to home-based exercise remained close to 55%. The most prominent factor associated with high adherence to supervised exercise was neoadjuvant chemotherapy [OR 7.09; 95% confidence interval (CI), 1.12-44.62]. For home-based exercise, lower adherence was seen in obese participants (OR 0.16; 95% CI, 0.04-0.65) and in participants with average or below average lower body muscle strength at baseline (OR 0.12; 95% CI, 0.03-0.46). Conclusion: The results of this study offer valuable information on factors associated with adherence to a program of supervised and home-based exercise. Interventions may be adapted to ensure higher adherence rates through supportive efforts targeted to women who are obese, have low muscle strength and who receive no or adjuvant chemotherapy (as opposed to neoadjuvant chemotherapy) during exercise.

Yoga-Specific Enhancement of Quality of Life Among Women With Breast Cancer: Systematic Review and Exploratory Meta-Analysis of Randomized Controlled Trials

Physical activities during and after cancer treatment have favorable psychosocial effects. Increasingly, yoga has become a popular approach to improving the quality of life (QoL) of women with breast cancer. However, the extant synthetic evidence on yoga has not used other exercise comparison conditions. This meta-analysis aimed to systematically assess yoga-specific effects relative to any other physical exercise intervention (eg, aerobics) for women with breast cancer. QoL was the primary outcome of interest. Eight randomized controlled trials with 545 participants were included. The sample-weighted synthesis at immediate postintervention revealed marginally statistically and modest practically significant differences suggesting yoga's potentially greater effectiveness: d = 0.14, P = .10. However, at longer term follow-up, no statistically or practically significant between-group difference was observed. This meta-analysis preliminarily demonstrated that yoga is probably as effective as other exercise modalities in improving the QoL of women with breast cancer. Both interventions were associated with clinically significant improvements in QoL. Nearly all of the yoga intervention programs, however, were very poorly resourced. Larger and better controlled trials of well-endowed yoga programs are needed.

Exercise interventions for people undergoing multimodal cancer treatment that includes surgery

BACKGROUND

People undergoing multimodal cancer treatment are at an increased risk of adverse events. Physical fitness significantly reduces following cancer treatment, which is related to poor postoperative outcome. Exercise training can stimulate skeletal muscle adaptations, such as increased mitochondrial content and improved oxygen uptake capacity may contribute to improved physical fitness.

OBJECTIVES

To determine the effects of exercise interventions for people undergoing multimodal treatment for cancer, including surgery, on physical fitness, safety, health-related quality of life (HRQoL), fatigue, and postoperative outcomes.

SEARCH METHODS

We searched electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, SPORTDiscus, and trial registries up to October 2018.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the effects of exercise training with usual care, on physical fitness, safety, HRQoL, fatigue, and postoperative outcomes in people undergoing multimodal cancer treatment, including surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, performed the data extraction, assessed the risk of bias, and rated the quality of the studies using Grading of Recommendation Assessment, Development, and Evaluation (GRADE) criteria. We pooled data for meta-analyses, where possible, and reported these as mean differences using the random-effects model.

MAIN RESULTS

Eleven RCTs were identified involving 1067 participants; 568 were randomly allocated to an exercise intervention and 499 to a usual care control group. The majority of participants received treatment for breast cancer (73%). Due to the nature of the intervention, it was not possible to blind the participants or personnel delivering the intervention. The risk of detection bias was either high or unclear in some cases, whilst most other domains were rated as low risk. The included studies were of moderate to very low-certainty evidence. Pooled data demonstrated that exercise training may have little or no difference on physical fitness (VO₂ max) compared to usual care (mean difference (MD) 0.05 L/min^-1, 95% confidence interval (CI) -0.03 to 0.13; I² = 0%; 2 studies, 381 participants; low-certainty evidence). Included studies also showed in terms of adverse effects (safety), that it may be of benefit to exercise (8 studies, 507 participants; low-certainty evidence). Furthermore, exercise training probably made little or no difference on HRQoL (EORTC global health status subscale) compared to usual care (MD 2.29, 95% CI -1.06 to 5.65; I² = 0%; 3 studies, 472 participants; moderate-certainty evidence). However, exercise training probably reduces fatigue (multidimensional fatigue inventory) compared to usual care (MD -1.05, 95% CI -1.83 to -0.28; I² = 0%; 3 studies, 449 participants moderate-certainty evidence). No studies reported postoperative outcomes.

AUTHORS' CONCLUSIONS

The findings should be interpreted with caution in view of the low number of studies, the overall low-certainty of the combined evidence, and the variation in included cancer types (mainly people with breast cancer), treatments, exercise interventions, and outcomes. Exercise training may, or may not, confer modest benefit on physical fitness and HRQoL. Limited evidence suggests that exercise training is probably not harmful and probably reduces fatigue. These findings highlight the need for more RCTs, particularly in the neoadjuvant setting.

Exercise Prescription and Adherence for Breast Cancer: One Size Does Not FITT All

PURPOSE

To prospectively assess adherence to oncologist-referred, exercise programming consistent with current recommendations for cancer survivors among women with early breast cancer across the trajectory of adjuvant treatment.

METHODS

Sixty-eight women participated in supervised, hour-long, moderate-intensity, aerobic, and resistance exercise thrice per week during adjuvant chemotherapy ± radiation, with a step-down in frequency for 20 additional weeks. Adherence to exercise frequency (i.e., attendance), intensity, and time/duration, and barriers to adherence were tracked and compared during chemotherapy versus radiation, and during treatment (chemotherapy plus radiation, if received) versus after treatment.

RESULTS

Attendance decreased with cumulative chemotherapy dose (cycles 1-2 vs cycles 3-8, cycle 3 vs cycles 7-8, all P ≤ 0.05) and was lower during chemotherapy than radiation (64% ± 25% vs 71% ± 32%, P = 0.02) and after treatment than during treatment (P < 0.01). Adherence to exercise intensity trended toward being higher during chemotherapy than radiation (69% ± 23% vs 51% ± 38%, P = 0.06) and was higher during than after treatment (P = 0.01). Adherence to duration did not differ with treatment. Overall adherence to the resistance prescription was poor, but was higher during chemotherapy than radiation (57% ± 23% vs 34% ± 39%, P < 0.01) and was not different during than after treatment. The most common barriers to attendance during treatment were cancer-related (e.g., symptoms, appointments), and after treatment were life-related (e.g., vacation, work).

CONCLUSIONS

Adherence to supervised exercise delivered in a real-world clinical setting varies among breast cancer patients and across the treatment trajectory. Behavioral strategies and individualization in exercise prescriptions to improve adherence are especially important for later chemotherapy cycles, after treatment, and for resistance exercise.

Targeting Exercise Interventions to Patients With Cancer in Need: An Individual Patient Data Meta-Analysis

Background

Exercise effects in cancer patients often appear modest, possibly because interventions rarely target patients most in need. This study investigated the moderator effects of baseline values on the exercise outcomes of fatigue, aerobic fitness, muscle strength, quality of life (QoL), and self-reported physical function (PF) in cancer patients during and post-treatment.

Methods

Individual patient data from 34 randomized exercise trials (n = 4519) were pooled. Linear mixed-effect models were used to study moderator effects of baseline values on exercise intervention outcomes and to determine whether these moderator effects differed by intervention timing (during vs post-treatment). All statistical tests were two-sided.

Results

Moderator effects of baseline fatigue and PF were consistent across intervention timing, with greater effects in patients with worse fatigue (Pinteraction = .05) and worse PF (Pinteraction = .003). Moderator effects of baseline aerobic fitness, muscle strength, and QoL differed by intervention timing. During treatment, effects on aerobic fitness were greater for patients with better baseline aerobic fitness (Pinteraction = .002). Post-treatment, effects on upper (Pinteraction < .001) and lower (Pinteraction = .01) body muscle strength and QoL (Pinteraction < .001) were greater in patients with worse baseline values.

Conclusion

Although exercise should be encouraged for most cancer patients during and post-treatments, targeting specific subgroups may be especially beneficial and cost effective. For fatigue and PF, interventions during and post-treatment should target patients with high fatigue and low PF. During treatment, patients experience benefit for muscle strength and QoL regardless of baseline values; however, only patients with low baseline values benefit post-treatment. For aerobic fitness, patients with low baseline values do not appear to benefit from exercise during treatment.

Improvement of well-being in cancer patients by yoga training

Background: Cancer patients frequently suffer from a reduced physical activity. Non-pharmacological interventions, such as yoga, provide opportunities to deal with these symptoms. The aim of this study is to evaluate the effect of yoga on the well-being of cancer patients.Methods: Between 2015 and 2017, we analyzed the effects of yoga on the well-being of cancer patients. Fifty-one patients received yoga training specifically designed to address cancer-related problems. Before the start (SoS) and after the end (EoS) of training, the WHO-5 well-being index was used to evaluate patients’ perception.Results: WHO-5 scores significantly improved from 47.1±21.4 at SoS to 69.7±15.1 at EoS. Patients in the middle age group (EoS–SoS: 28.0±20.6) showed a significantly higher benefit (p<0.005) compared with age groups <40 years (EoS–SoS: 10.7±15.4) and >60 years (EoS–SoS: 16.0±12.1). Patients with low initial scores benefited most from yoga.Conclusion: Our study showed that yoga training under experienced supervision could serve as a beneficial complementary treatment in cancer patients. Best effects were observed in patients with highly reduced well-being and 40–60-year-old patients.

Barriers to physical activity: a study of academic and community cancer survivors with pain

PURPOSE

Despite the numerous benefits of physical activity (PA) for patients with cancer, many cancer survivors report challenges to participating in PA. The objectives of this study were (1) to assess barriers to PA and (2) to examine participant characteristics associated with modifiable barriers to PA among cancer survivors with pain.

METHODS

We conducted a cross-sectional survey study at one academic medical center and 11 community hospitals. Participants completed the 12-item Physical Activity Barriers After Cancer (PABAC) instrument (Cronbach's alpha = 0.75). Multivariable regression models examined participant characteristics associated with PABAC scores with a higher score indicating more barriers to PA.

RESULTS

Among 662 survivors, 67% had moderate or severe pain (rating 4 or greater on a scale of 0 to 10). Seventy-five percent of survivors did not meet the American Cancer Society PA recommendations on average, and these individuals had higher mean PABAC scores (beta coefficient (β) = 2.02, 95% confidence interval (CI) 0.96-3.09, p < 0.001). In adjusted analyses, cancer survivors who were non-white (β = 1.55, 0.28-2.82, p = 0.02), treated at a community hospital (β = 1.07, 0.09-2.05, p = 0.03), had surgery (β = 1.69, 0.69-2.69, p = 0.001), or within 12 months of diagnosis (β = 1.15, 0.20-2.10, p = 0.02) reported greater barriers to PA.

CONCLUSIONS

The majority of cancer survivors with pain are not adequately participating in PA. Key demographic and clinical characteristics are associated with survivors' barriers.

IMPLICATIONS FOR CANCER SURVIVORS

Efforts to overcome specific barriers are needed to promote PA after a cancer diagnosis.

[Physical Activity and Cancer]

Physical Activity and Cancer Abstract. This article aims to summarize the literature on the role of physical activity in cancer patients and to propose exercise programs based on studies and recommendations. Medical advances with improved early diagnosis and treatment have increased the number of cancer survivors. At the same time, the quality of life of these patients must also be improved. In the different stages of the disease physical activity has an important role to play with its beneficial effects on fatigue, physical condition, mood etc. Collaboration between health system actors and patient education are the key to success in this multi-disciplinary care.

A Patient-Centered Activity Regimen Improves Participation in Physical Activity Interventions in Advanced-Stage Lung Cancer

INTRODUCTION

Physical activity (PA) is a potential therapy to improve quality of life in patients with advanced-stage lung cancer (LC), but no PA regimen has been shown to be beneficial, clinically practical, and sustainable. We sought to test the hypothesis that a patient-centered activity regimen (PCAR) will improve patient participation and PA more effectively than weekly phone calls.

METHODS

In patients with advanced-stage LC, we implemented a walking-based activity regimen and motivated patients via either weekly phone calls (n = 29; FitBit Zip accelerometer) or PCAR (n = 15; FitBit Flex, an educational session, and twice-daily gain-framed text messages). Data collection over a 4-week period was compared, and a repeated-measures, mixed-effects model for activity level was constructed.

RESULTS

Subjects receiving PCAR more frequently used the device (100% vs 79%) and less frequently had missing data (11% vs 38%). "More active" and "less active" groups were created based on mean step count in the first week. "Less active" patients in the PCAR group increased their PA level, whereas PA level fell in the "more active" group. Most subjects found PCAR helpful (92%) and would participate in another activity study (85%).

DISCUSSION

Compared with weekly phone calls, PCAR has higher patient participation, is more likely to improve PA in "less active" subjects, and has high patient satisfaction. A multifaceted PA regimen may be a more efficacious mechanism to study PA in advanced LC. PCAR should be used in a randomized controlled trial to evaluate for improvements in symptom burden, quality of life, and mood.

Self-monitoring physical activity with a smartphone application in cancer patients: a randomized feasibility study (SMART-trial)

Purpose

Evidence accumulates that an active lifestyle positively influences cancer treatment outcome. A “smartphone application” (app) such as “RunKeeper,” to self-monitor physical activity (PA) might be helpful. This study aimed to examine whether using RunKeeper to increase self-reported PA is feasible in cancer patients and to evaluate patients’ opinion about using RunKeeper in a 12-week program.

Methods

Adult patients (n = 32), diagnosed with cancer, were randomized between usual care (n = 16) or a 12-week intervention with instructions to self-monitor PA with RunKeeper (n = 16). Changes in PA were determined with the Physical Activity Scale for the Elderly (PASE) at baseline (T0), 6 weeks (T1), and 12 weeks (T2). Usability and patients’ experiences were tested at T2 with the System Usability Scale (SUS) and a semi-structured interview.

Results

Patient mean age was 33.6 years. Between T0 and T1, an increase in PA of 51% (medium estimated effect size r = 0.40) was found in PASE sum score in the intervention group compared with usual care. In addition, total minutes of PA increased with 46% (r = 0.37). These effects decreased over time (T2). Sedentary time decreased with 19% between T0 and T1 and 27% between T0 and T2. Usability was rated “good” and most patients found RunKeeper use helpful to improve PA.

Conclusions

Self-monitoring PA with RunKeeper was safe and feasible in cancer patients. The RunKeeper use resulted in an increase in PA after 6 weeks. RunKeeper usability was rated good and can be used to study PA in cancer patients.

Trial registration

NCT02391454

Electronic supplementary material

The online version of this article (10.1007/s00520-018-4263-5) contains supplementary material, which is available to authorized users.

A Restorative Yoga Intervention for African-American Breast Cancer Survivors: a Pilot Study

BACKGROUND

Data show that yoga is effective for improving health-related outcomes in breast cancer survivors. While breast cancer is the most commonly diagnosed cancer among African-American women (AAW), AAW are less likely to engage in yoga compared to other ethnic groups. The goals of the current study were to assess the feasibility of an 8-week restorative yoga program among African-American breast cancer survivors (AA BCS). Specifically, study aims were to (1) measure changes in study outcomes in a restorative yoga (RY) group compared to a wait list control group, (2) assess adherence to the RY program, and (3) assess program satisfaction among study participants.

METHODS

Thirty-three AA BCS were randomly assigned to either the RY intervention (n = 18) or wait list control group (n = 15). RY classes met once per week for 8 weeks. Pre- and post-testing assessments were measured at 0 and 8 weeks (immediately post-intervention).

RESULTS

Depression scores at follow-up were significantly lower in the yoga group (M = 4.78, SD = 3.56) compared to the control group (M = 6.91, SD = 5.86). No significant group differences were observed for sleep quality, fatigue, or perceived stress. Yoga program participants completing baseline assessments demonstrated 61% adherence to the yoga classes. Average rating of the yoga program was "very useful." Recommendations for future yoga programs were provided.

CONCLUSIONS

This study suggests that yoga has a beneficial effect on depression in AA BCS. There is, however, a need to further explore the benefits of yoga among minority breast cancer survivors using a study with larger sample sizes.

Predictors of adherence to exercise interventions during and after cancer treatment: A systematic review

Objective

Exercise interventions benefit cancer patients. However, only low numbers of patients adhere to these interventions. This review aimed to identify predictors of exercise intervention adherence in patients with cancer, during and after multimodality cancer treatment.

Methods

A literature search was performed using electronic databases (PubMed, Embase, and Cochrane) to identify relevant papers published before February 1, 2017. Papers reporting randomized controlled trials, conducted in adult cancer patients who participated in an exercise intervention during and/or after multimodality cancer treatment, and providing outcome of factors predicting exercise adherence were included. Papers were assessed for methodological quality by using the Physiotherapy Evidence Database scale.

Results

The search identified 720 potentially relevant papers, of which 15 fulfilled the eligibility criteria. In these 15 studies, 2279 patients were included and 1383 of these patients were randomized to an exercise intervention. During cancer treatment, the factors predicting exercise adherence were as follows: location of the rehabilitation center, extensive exercise history, high motivation for exercise, and fewer exercise limitations. After cancer treatment, factors that predicted adherence were as follows: less extensive surgery, low alcohol consumption, high previous exercise adherence, family support, feedback by trainers, and knowledge and skills of exercise. Methodological quality of the included papers was rated “high”.

Conclusions

The most prominent predictors of adherence to exercise interventions were location of the rehabilitation center, extensive exercise history, high motivation for exercise, and fewer exercise limitations. To increase the number of cancer patients who will benefit, these results should be considered into the development and implementation of future exercise interventions.

The Interdisciplinary Rehabilitation Care Team and the Role of Physical Therapy in Survivor Exercise

BACKGROUND

Rehabilitation professionals offer expertise in functional assessment, treatment of impairments and functional limitations, and disability prevention. To optimize recovery, and often prior to participating in community-based exercise programming, survivors may need rehabilitation services from a range of healthcare professionals, including physiatrists, nurses, nutritionists, psychologists, and speech, occupational, and physical therapists.

OBJECTIVES

Survivors with physical impairments and functional limitations may benefit from interdisciplinary rehabilitation and physical therapy, including tailored therapeutic exercise interventions.

METHODS

A literature review was conducted using the key words cancer survivor, cancer rehabilitation, impairment, fatigue, lymphedema, chemotherapy-induced peripheral neuropathy, and exercise. MEDLINE®, EMBASE, Cochrane Database of Systematic Reviews, and CINAHL® databases were searched.

FINDINGS

Nurses play a critical role in identifying survivors whose function or fitness is compromised to the point where participation in community-based exercise programming would be inappropriate or unsafe. The interdisciplinary rehabilitation care team can help facilitate the survivor's transition to community-based exercise programming.

Barriers to physical activity and healthy diet among breast cancer survivors: A multilevel perspective

Cancer survivors engage in suboptimal levels of health behaviours and report many barriers to health behaviours, but we lack a solid understanding of the different levels of barriers and how they relate to enacted health behaviours. To address these issues, we conducted mixed-method research in 97 breast cancer survivors. Participants' barriers to physical activity (PA) and healthy diet, asked as an open-ended question, were coded as individual-level, social-level, and organisational/environmental-level for each health behaviour. Moderate-to-vigorous PA and fruit and vegetable (F&V) intake were assessed. Most participants perceived at least one PA (72.7%) and diet (64.9%) individual-level barrier (e.g. physical symptoms/injury); only 15.2% (PA) and 15.6% (diet) reported at least one social-level barrier (e.g. family obligations). About 28.8% (PA) and 29.9% (diet) perceived at least one organisational/environmental-level barrier (e.g. job demand, cost of F&V). Survivors perceiving individual-level dietary barriers consumed less F&V (-.65 servings/day) than those not perceiving dietary barriers at this level. Survivors perceiving social-level dietary barriers reported marginally lower F&V intake (-.65 servings/day) than their counterparts. Those perceiving organisational/environmental-level PA barriers reported marginally fewer minutes (-44.30/week) of moderate-to-vigorous PA than their counterparts. Barriers at multiple levels should be addressed to improve health behaviours among breast cancer survivors.

Feasibility of a physical activity intervention during and shortly after chemotherapy for testicular cancer

Background

Given the risk of developing acute and long-term adverse effects in patients receiving cisplatin-based chemotherapy for testicular cancer (TC), risk-reducing interventions, such as physical activity (PA), may be relevant. Limited knowledge is available on the challenges met when conducting PA intervention trials in patients with TC during and shortly after chemotherapy. The aims of the present feasibility study are therefore to determine patient recruitment, compliance and adherence to a PA intervention.

Results

Patients with metastatic TC referred to cisplatin-based chemotherapy were eligible. They followed an individual low-threshold PA intervention, including counseling from a personal coach during and 3 months after chemotherapy. Outcomes were recruitment rate, compliance rate and adherence to the intervention including preferences for type of PA and barriers for PA. During 8 months 12 of 18 eligible patients were invited, all consented, but three dropped out. Walking and low intensity activities were preferred and nausea and feeling unwell were the most often reported barriers towards PA.

Discussion

In order to achieve adequate recruitment, compliance and complete data in future PA intervention trials, close cooperation with treating physicians, individual PA plans and availability of personalized coaching are required.

Trial registration NCT01749774, November 2012, ClinicalTrials.gov

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2531-y) contains supplementary material, which is available to authorized users.

Rethinking barriers: a novel conceptualization of exercise barriers in cancer survivors

Previous research suggests different types of barriers may demonstrate different relationships with intention to engage in health behaviors. This study explored global, practical, and health-related barriers' relationships with exercise intention and behavior among cancer survivors. The mediating role of intention in the barriers-behavior relationships was also evaluated. Cancer survivors (N = 152) completed self-report measures of exercise barriers, intention, and behavior at baseline and of exercise behavior two months later. Global barriers were negatively related (p < .01) and practical and health-related barriers were unrelated (ps ≥ .07) to exercise intention. Global and practical barriers were negatively related (ps < .01) and health-related barriers were unrelated (p = .48) to subsequent exercise behavior. Exercise intention did not mediate any barriers-behavior relationships. Results suggest that global and practical barriers should be targeted in barriers reduction interventions and highlight the intention-behavior gap problem. Future research should explore multidimensionality of barriers for other health behaviors.

Exercise for women receiving adjuvant therapy for breast cancer

BACKGROUND

A huge clinical research database on adjuvant cancer treatment has verified improvements in breast cancer outcomes such as recurrence and mortality rates. On the other hand, adjuvant and neoadjuvant therapy with chemotherapy and radiotherapy impacts on quality of life due to substantial short- and long-term side effects. A number of studies have evaluated the effect of exercise interventions on those side effects. This is an updated version of the original Cochrane review published in 2006. The original review identified some benefits of physical activity on physical fitness and the resulting capacity for performing activities of daily life. It also identified a lack of evidence for other outcomes, providing clear justification for an updated review.

OBJECTIVES

To assess the effect of aerobic or resistance exercise interventions during adjuvant treatment for breast cancer on treatment-related side effects such as physical deterioration, fatigue, diminished quality of life, depression, and cognitive dysfunction.

SEARCH METHODS

We carried out an updated search in the Cochrane Breast Cancer Group Specialised Register (30 March 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2015), MEDLINE (1966 to 30 March 2015), and EMBASE (1966 to 30 March 2015). We did not update the original searches in CINAHL (1982 to 2004), SPORTDiscus (1975 to 2004), PsycINFO (1872 to 2003), SIGLE (1880 to 2004), and ProQuest Digital Dissertations (1861 to 2004). We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials on 30 March 2015. We screened references in relevant reviews and published clinical trials.

SELECTION CRITERIA

We included randomised controlled trials that examined aerobic or resistance exercise or both in women undergoing adjuvant treatment for breast cancer. Published and unpublished trials were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction, assessed trials, and graded the methodological quality using Cochrane's 'Risk of bias' tool. Any disagreements were resolved through discussion or by consulting the third review author. We entered data into Review Manager for analysis. For outcomes assessed with a variety of instruments, we used the standardised mean difference (SMD) as a summary statistic for meta-analysis; for those assessed with the same instrument, we used the mean difference (MD).

MAIN RESULTS

For this 2015 update we included a total of 32 studies with 2626 randomised women, 8 studies from the original search and 24 studies from the updated search. We found evidence that physical exercise during adjuvant treatment for breast cancer probably improves physical fitness (SMD 0.42, 95% confidence interval (CI) 0.25 to 0.59; 15 studies; 1310 women; moderate-quality evidence) and slightly reduces fatigue (SMD -0.28, 95% CI -0.41 to -0.16; 19 studies; 1698 women; moderate-quality evidence). Exercise may lead to little or no improvement in health-related quality of life (MD 1.10, 95% CI -5.28 to 7.48; 1 study; 68 women; low-quality evidence), a slight improvement in cancer site-specific quality of life (MD 4.24, 95% CI -1.81 to 10.29; 4 studies; 262 women; low-quality evidence), and an improvement in cognitive function (MD -11.55, 95% CI -22.06 to -1.05; 2 studies; 213 women; low-quality evidence). Exercise probably leads to little or no difference in cancer-specific quality of life (SMD 0.12, 95% CI 0.00 to 0.25; 12 studies; 1012 women; moderate-quality evidence) and little or no difference in depression (SMD -0.15, 95% CI -0.30 to 0.01; 5 studies; 674 women; moderate-quality evidence). Evidence for other outcomes ranged from low to moderate quality. Seven trials reported a very small number of adverse events.

AUTHORS' CONCLUSIONS

Exercise during adjuvant treatment for breast cancer can be regarded as a supportive self care intervention that probably results in less fatigue, improved physical fitness, and little or no difference in cancer-specific quality of life and depression. Exercise may also slightly improve cancer site-specific quality of life and cognitive function, while it may result in little or no difference in health-related quality of life. This review is based on trials with a considerable degree of clinical heterogeneity regarding adjuvant cancer treatments and exercise interventions. Due to the difficulty of blinding exercise trials, all included trials were at high risk for performance bias. Furthermore, the majority of trials were at high risk for detection bias, largely due to most outcomes being self reported.The findings of the updated review have enabled us to make a more precise conclusion that both aerobic and resistance exercise can be regarded as beneficial for individuals with adjuvant therapy-related side effects. Further research is required to determine the optimal type, intensity, and timing of an exercise intervention. Furthermore, long-term evaluation is required due to possible long-term side effects of adjuvant treatment.

Social support and social control in the context of cancer patients' exercise: A pilot study

Social support is an important factor for exercise among cancer patients, but too much control might elicit reactance and lead to detrimental effects. In this pilot study, 56 dyads (cancer patient + relative) filled out a questionnaire assessing social support, social control, and reactance. After 4 weeks (T2), patients' exercise was assessed with a 7-day recall. About half of the patients did not engage in any self-reported exercise behavior. Relative-reported support was the only variable associated with exercise behavior at T2. Perceived control (r = .4) but not perceived support was significantly correlated with reactance. Male patients reported more support, but were also more prone to reactance.

Physical activity prescription: a critical opportunity to address a modifiable risk factor for the prevention and management of chronic disease: a position statement by the Canadian Academy of Sport and Exercise Medicine

Non-communicable disease is a leading threat to global health. Physical inactivity is a large contributor to this problem; in fact, the WHO ranks it as the fourth leading risk factor for overall morbidity and mortality worldwide. In Canada, at least 4 of 5 adults do not meet the Canadian Physical Activity Guidelines of 150 min of moderate-to-vigorous physical activity per week. Physicians play an important role in the dissemination of physical activity (PA) recommendations to a broad segment of the population, as over 80% of Canadians visit their doctors every year and prefer to get health information directly from them. Unfortunately, most physicians do not regularly assess or prescribe PA as part of routine care, and even when discussed, few provide specific recommendations. PA prescription has the potential to be an important therapeutic agent for all ages in primary, secondary and tertiary prevention of chronic disease. Sport and exercise medicine (SEM) physicians are particularly well suited for this role and should collaborate with their primary care colleagues for optimal patient care. The purpose of this Canadian Academy and Sport and Exercise Medicine position statement is to provide an evidence-based, best practices summary to better equip SEM and primary care physicians to prescribe PA and exercise, specifically for the prevention and management of non-communicable disease. This will be achieved by addressing common questions and perceived barriers in the field.Author note This position statement has been endorsed by the following nine sport medicine societies: Australasian College of Sports and Exercise Physicians (ACSEP), American Medical Society for Sports Medicine (AMSSM), British Association of Sports and Exercise Medicine (BASEM), European College of Sport & Exercise Physicians (ECOSEP), Norsk forening for idrettsmedisin og fysisk aktivite (NIMF), South African Sports Medicine Association (SASMA), Schweizerische Gesellschaft für Sportmedizin/Swiss Society of Sports Medicine (SGSM/SSSM), Sport Doctors Australia (SDrA), Swedish Society of Exercise and Sports Medicine (SFAIM), and CASEM.

Cancer patients participating in a lifestyle intervention during chemotherapy greatly over-report their physical activity level: a validation study

BACKGROUND

The short form of the International Physical Activity Questionnaire (IPAQ-sf) is a validated questionnaire used to assess physical activity (PA) in healthy adults and commonly used in both apparently healthy adults and cancer patients. However, the IPAQ-sf has not been previously validated in cancer patients undergoing oncologic treatment. The objective of the present study was to compare IPAQ-sf with objective measures of physical activity (PA) in cancer patients undergoing chemotherapy.

METHODS

The present study was part of a 12-month prospective individualized lifestyle intervention focusing on diet, PA, stress management and smoking cessation in 100 cancer patients undergoing chemotherapy. During the first two months of the lifestyle intervention, participants were wearing an activity monitor (SenseWear™ Armband (SWA)) for five consecutive days while receiving chemotherapy before completing the IPAQ-sf. From SWA, Moderate-to-Vigorous intensity PA (MVPA) in bouts ≥10 min was compared with self-reported MVPA from the IPAQ-sf. Analyses both included and excluded walking in MVPA from the IPAQ-sf. Results were extrapolated to a wearing time of seven days.

RESULTS

Sixty-six patients completed IPAQ-sf and wore the SWA over five days. Mean difference and limit of agreement between the IPAQ-sf and SWA including walking was 662 (±1719) min(.)wk(-1). When analyzing time spent in the different intensity levels separately, IPAQ-sf reported significantly higher levels of moderate (602 min(.)wk(-1), p = 0.001) and vigorous (60 min(.)wk(-1), p = 0.001) PA compared to SWA.

CONCLUSIONS

Cancer patients participating in a lifestyle intervention during chemotherapy reported 366 % higher MVPA level from the past seven days using IPAQ-sf compared to objective measures. The IPAQ-sf appears insufficient when assessing PA level in cancer patients undergoing oncologic treatment. Activity monitors or other objective tools should alternatively be considered, when assessing PA in this population.