Is referral of postsurgical colorectal cancer survivors to cardiac rehabilitation feasible and acceptable? A pragmatic pilot randomised controlled trial with embedded qualitative study

Time to embed physical activity within usual care in cancer services: A qualitative study of cancer healthcare professionals' views at a single centre in England

PURPOSE

An increasing number of people affected by cancer (PABC) are living longer lives as treatment continues to advance. There is growing evidence for physical activity (PA) supporting health in this population before, during and after cancer treatment, but PA advice is not part of usual care. This study investigates views of frontline oncology healthcare professionals (HCPs) in one NHS teaching hospital in England to understand the role of PA advice across cancer services.

MATERIALS AND METHODS

This was a qualitative study interviewing HCPs and using thematic analysis.

RESULTS

Four main themes were identified: 1. Awareness of the roles of PA in cancer; 2. Patient-specific factors in rehabilitation; 3. Cancer-specific factors in rehabilitation; 4. Barriers and opportunities to integrating PA within usual care. HCPs' awareness of the role of PA in cancer rehabilitation was low overall and PA was found not to be embedded within rehabilitation. Contrastingly, there was awareness of PA's potential to impact disease and treatment-related outcomes positively. Ideas for PA integration included training for staff and giving PA advice within consultations.

CONCLUSIONS

Low awareness of benefits of PA-based rehabilitation and lack of integration in usual care contrasted with HCPs' interest in this area's potential. Training HCPs to begin the conversation with patients affected by cancer in teachable moments may increase patient access.Implications for rehabilitationIntegrating physical activity education and training for trainees and existing healthcare professionals workforce would help embed physical activity into routine clinical practice.Brief advice intervention training during every consultation, such as providing relevant individualised information and signposting, can be impactful.Physical activity within a broader cancer rehabilitation programme should be integrated as standard for every cancer patient.Individualised plans may include prehabilitation, restorative rehabilitation and palliative rehabilitation.Patient preferences and the patient experience should continue to shape service design.There is a need to ensure physical activity advice is consistent throughout healthcare settings and not fragmented between primary, secondary and tertiary care.

Effectiveness of the perioperative encounter in promoting regular exercise and physical activity: a systematic review and meta-analysis

BACKGROUND

Low levels of physical activity (PA) are associated with poorer health outcomes. The perioperative encounter (extending from initial contact in primary care to beyond discharge from hospital) is potentially a good time to intervene, but data regarding the effectiveness of interventions are scarce. To address this, we systematically reviewed existing literature to evaluate the effectiveness of interventions applied perioperatively to facilitate PA in the medium to long-term (at least six months after the intervention).

METHODS

In this systematic review and meta-analysis, we searched Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, CINAHL, Embase, PsycInfo, and SPORTDiscus from database inception to October 22nd 2020, with an updated search done on August 4th 2022. We searched clinical trials registers, and conducted forward- and backward-citation searches. We included randomised controlled trials and quasi-randomised trials comparing PA interventions with usual care, or another PA intervention, in adults who were scheduled for, or had recently undergone, surgery. We included trials which reported our primary outcomes: amount of PA or whether participants were engaged in PA at least six months after the intervention. A random effects meta-analysis was used to pool data across studies as risk ratios (RR), or standardised mean differences (SMDs), which we interpreted using Cohen. We used the Cochrane risk of bias tool and used GRADE to assess the certainty of the evidence. This study is registered with PROSPERO, CRD42019139008.

FINDINGS

We found 57 trials including 8548 adults and compared 71 interventions facilitating PA. Most interventions were started postoperatively and included multiple components. Compared with usual care, interventions may slightly increase the number of minutes of PA per day or week (SMD 0.17, 95% CI 0.09-0.26; 14 studies, 2172 participants; I² = 0%), and people's engagement in PA at the study's end (RR 1.19, 95% CI 0.96-1.47; 9 studies, 882 participants; I² = 25%); this was moderate-certainty evidence. Some studies compared two different types of interventions but it was often not feasible to combine data in analysis. The effect estimates generally indicated little difference between intervention designs and we judged all the evidence for these comparisons to be very low certainty. Thirty-six studies (63%) had low risk of selection bias for sequence generation, 27 studies (47%) had low risk of bias for allocation concealment, and 56 studies (98%) had a high risk of performance bias. For detection bias for PA outcomes, we judged 30 studies (53%) that used subjective measurement tools to have a high risk of detection bias.

INTERPRETATION

Interventions delivered in the perioperative setting, aimed at enhancing PA in the medium to long-term, may have overall benefit. However, because of imprecision in some of the findings, we could not rule out the possibility of no change in PA.

FUNDING

National Institute for Health Research Health Services and Delivery Research programme (NIHR127879).

Research Quality and Impact of Cardiac Rehabilitation in Cancer Survivors

Background

Cardiac rehabilitation (CR) is endorsed to improve cardiovascular outcomes in cancer survivors. The quality of CR-based research in oncology has not been assessed.

Objectives

The aim of this study was to evaluate the quality of reporting and evidence from CR-based intervention studies in oncology and to explore associations between intervention participation and outcomes.

Methods

Systematic searches of 5 databases were conducted (January 2020) and updated (September 2021). Randomized and nonrandomized studies evaluating CR-based interventions in adult cancer survivors during and after treatment were eligible. Independent reviewers extracted data using 2 reporting guidelines (Template for Intervention Description and Replication and Consolidated Standards for Reporting Trials Harms extension), risk of bias (ROB) assessment tools (Cochrane ROB 2.0 and Cochrane Risk of Bias in Non-Randomized Studies of Interventions), and a combined inventory (Tool for the Assessment of Study Quality and reporting in Exercise). A meta-analysis was used to explore pre-intervention/post-intervention differences for commonly assessed outcomes.

Results

Ten studies involving data from 685 survivors were included. The mean quality scores for intervention reporting (Template for Intervention Description and Replication) and harms (Consolidated Standards for Reporting Trials Harms extension) were 62% and 17%, respectively. There was moderate-to-high ROB across nonrandomized (Cochrane Risk of Bias in Non-Randomized Studies of Interventions score: 25%) and randomized (ROB 2.0 score: 50%) studies. The mean standardized cardiorespiratory fitness was higher (0.42; 95% CI: 0.27-0.57), fatigue was lower (−0.45; 95% CI: −0.55 to −0.34), and percent body fat (0.07; 95% CI: −0.23 to 0.38) was not different in survivors completing CR compared with those not completing CR.

Conclusions

CR-based studies in oncology have low-to-moderate reporting quality and moderate-to-high ROB limiting interpretation, reproducibility, and translation of this evidence into practice.

Cancer and cardiovascular disease: The impact of cardiac rehabilitation and cardiorespiratory fitness on survival

BACKGROUND

Cancer survivors are at increased risk for cardiovascular disease (CVD)-related morbidity and mortality. Exercise-based cardiac rehabilitation (CR) programs improve CVD risk factors, including cardiorespiratory fitness (CRF). The purpose of this study was to investigate: (1) the association between CR completion and survival, and (2) whether CRF improvements translate to increased survival among patients with comorbid cancer and CVD.

METHODS

Patients with CVD and pre-existing cancer (any type) were referred to a 12-week exercise-based CR program between 01/1996 and 03/2016. Peak metabolic equivalents (METs) were assessed by graded exercise test pre-CR and at 12-weeks. Kaplan-Meier survival and multivariate cox regressions were performed to evaluate impact of CR completion and clinically-meaningful CRF improvements [ΔMETs≥1] on survival, adjusting for relevant covariates.

RESULTS

Among 442 patients with CVD and cancer referred to CR (67 ± 10 years; 22% women), 361 (82%) completed CR. 102 deaths were recorded during the 12-year observation period. Compared to patients who did not complete CR, patients with comorbid cancer who completed CR demonstrated a survival advantage (63% vs 80.1%, p < .001). CRF improved among completers during the 12-week program (mean change = 0.87 ± 0.93 METs, p < .001); 41% experienced a clinically-meaningful ΔMETs≥1. A survival advantage was not observed in completers who experienced a ΔMETs≥1 improvement (p = .254).

CONCLUSION

Completing a 12-week exercise-based CR program improved CRF and increased survival in patients with CVD and comorbid cancer. The results highlight the survival benefits of completing a CR program among CVD patients who experience added barriers imposed by cancer treatment and survival.

Feasibility of integrating survivors of stroke into cardiac rehabilitation: A mixed methods pilot study

Background

Survivors of stroke are often deconditioned and have limited opportunities for exercise post-rehabilitation. Cardiac Rehabilitation (CR), a structured exercise program offered post-cardiac event in the United States (U.S.), may provide an opportunity for continued exercise.

The purpose of this study was to examine the feasibility of integrating survivors of stroke into an existing, hospital-based CR program through an assessment of (1) recruitment, uptake and retention, (2) adherence and fidelity, (3) acceptability and (4) safety.

Methods

A mixed methods design combined a single group, pre-post design, pilot feasibility study with an imbedded qualitative inquiry. Survivors of stroke were recruited into a standard 12-week, 36 visit CR program.

Results

Fifty-three survivors were referred, 29 started and 24 completed the program. Program uptake rate was 55% and completion rate was 83%. Eleven completers and one non-completer participated in the qualitative interviews. Program completers attended an average of 25.25 (SD 5.82) sessions with an average of 38.93 (SD 5.64) exercise minutes per session while reaching targeted rate of perceived exertion levels. Qualitative themes included perceived benefits of an individualized program in a group setting, positive interactions with qualified staff, opportunities for socialization, and regular monitoring and staff attentiveness promoting feelings of safety.

Conclusions

Survivors of stroke were able to meet Medicare standard dosage (frequency and session duration) and rate of perceived intensity goals, and perceived the program as needed regardless of their mobility limitations or previous exercise experience. Primary challenges included managing referrals and uptake. Results support feasibility and benefit for survivors to integrate into U.S. CR programs.

Multidisciplinary, exercise-based oncology rehabilitation programs improve patient outcomes but their effects on healthcare service-level outcomes remain uncertain: a systematic review

QUESTION

What is the effect of multidisciplinary, exercise-based, group oncology rehabilitation programs on healthcare service outcomes and patient-level outcomes, including quality of life and physical and psychosocial function?

DESIGN

Systematic review with meta-analysis of randomised controlled trials.

PARTICIPANTS

Adults diagnosed with cancer.

INTERVENTION

Multidisciplinary, group-based rehabilitation that includes exercise for cancer survivors.

OUTCOME MEASURES

Primary outcomes related to health service delivery, including costs, hospitalisations and healthcare service utilisation. Secondary outcomes were patient-level measures, including: the European Organisation for Research and Treatment of Cancer Quality-of-life Questionnaire, 30-second timed sit to stand and the Hospital Anxiety and Depression Scale. The evidence was evaluated using the PEDro Scale and the Grades of Research, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Seventeen trials (1,962 participants) were included. There was uncertainty about the effect of multidisciplinary, exercise-based rehabilitation on healthcare service outcomes, as only one trial reported length of stay and reported wide confidence intervals (MD 2.4 days, 95% CI -3.1 to 7.8). Multidisciplinary, exercise-based rehabilitation improved muscle strength (1RM chest press MD 3.6 kg, 95% CI 0.4 to 6.8; 1RM leg press MD 19.5 kg, 95% CI 12.3 to 26.8), functional strength (30-second sit to stand MD 6 repetitions, 95% CI 3 to 9) and reduced depression (MD -0.7 points, 95% CI -1.2 to -0.1) compared to usual care. There was uncertainty whether multidisciplinary rehabilitation programs are more effective when delivered early versus late or more effective than exercise alone. Adherence was typically high (mean weighted average 76% sessions attended) with no major and few minor adverse events reported.

CONCLUSION

Multidisciplinary, exercise-based oncology rehabilitation programs improve some patient-level outcomes compared with usual care. Further evidence from randomised trials to determine their effect at a healthcare service level are required if these programs are to become part of standard care.

TRIAL REGISTRATION

PROSPERO CRD42019130593.

Cardiac Rehabilitation Programs for Cancer Survivors: A Scoping Review

Purpose of review

Participation in cardiac rehabilitation is associated with improved quality of life and physical functioning and may be an effective strategy to assist in the recovery from cancer. We conducted a scoping review to identify studies that enrolled cancer survivors into cardiac rehabilitation programs.

Recent findings

We identified nine studies that included 662 cancer survivors. Five studies integrated cancer survivors and cardiac patients into the same sessions, three studies developed cancer-only rehabilitation sessions, and one study did not report details on the rehabilitation sessions. On average, more than 60% of enrolled cancer survivors completed the rehabilitation programs and many health and psychosocial outcomes improved after rehabilitation.

Summary

Cardiac rehabilitation appears to be acceptable and favorably impacts many health and psychosocial outcomes among cancer survivors. Future research should consider randomized controlled trial study designs, enrolling diverse survivor populations, and using a set of core physical function and psychosocial outcomes.

Physical activity interventions for disease-related physical and mental health during and following treatment in people with non-advanced colorectal cancer

BACKGROUND

Colorectal cancer is the third most commonly diagnosed cancer worldwide. A diagnosis of colorectal cancer and subsequent treatment can adversely affect an individuals physical and mental health. Benefits of physical activity interventions in alleviating treatment side effects have been demonstrated in other cancer populations. Given that regular physical activity can decrease the risk of colorectal cancer, and cardiovascular fitness is a strong predictor of all-cause and cancer mortality risk, physical activity interventions may have a role to play in the colorectal cancer control continuum. Evidence of the efficacy of physical activity interventions in this population remains unclear.

OBJECTIVES

To assess the effectiveness and safety of physical activity interventions on the disease-related physical and mental health of individuals diagnosed with non-advanced colorectal cancer, staged as T1-4 N0-2 M0, treated surgically or with neoadjuvant or adjuvant therapy (i.e. chemotherapy, radiotherapy or chemoradiotherapy), or both.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 6), along with OVID MEDLINE, six other databases and four trial registries with no language or date restrictions. We screened reference lists of relevant publications and handsearched meeting abstracts and conference proceedings of relevant organisations for additional relevant studies. All searches were completed between 6 June and 14 June 2019.

SELECTION CRITERIA

We included randomised control trials (RCTs) and cluster-RCTs comparing physical activity interventions, to usual care or no physical activity intervention in adults with non-advanced colorectal cancer.

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 GRADE criteria. We pooled data for meta-analyses by length of follow-up, reported as mean differences (MDs) or standardised mean differences (SMDs) using random-effects wherever possible, or the fixed-effect model, where appropriate. If a meta-analysis was not possible, we synthesised studies narratively.

MAIN RESULTS

We identified 16 RCTs, involving 992 participants; 524 were allocated to a physical activity intervention group and 468 to a usual care control group. The mean age of participants ranged between 51 and 69 years. Ten studies included participants who had finished active treatment, two studies included participants who were receiving active treatment, two studies included both those receiving and finished active treatment. It was unclear whether participants were receiving or finished treatment in two studies. Type, setting and duration of physical activity intervention varied between trials. Three studies opted for supervised interventions, five for home-based self-directed interventions and seven studies opted for a combination of supervised and self-directed programmes. One study did not report the intervention setting. The most common intervention duration was 12 weeks (7 studies). Type of physical activity included walking, cycling, resistance exercise, yoga and core stabilisation exercise. Most of the uncertainty in judging study bias came from a lack of clarity around allocation concealment and blinding of outcome assessors. Blinding of participants and personnel was not possible. The quality of the evidence ranged from very low to moderate overall. We did not pool physical function results at immediate-term follow-up due to considerable variation in results and inconsistency of direction of effect. We are uncertain whether physical activity interventions improve physical function compared with usual care. We found no evidence of effect of physical activity interventions compared to usual care on disease-related mental health (anxiety: SMD -0.11, 95% confidence interval (CI) -0.40 to 0.18; 4 studies, 198 participants; I2 = 0%; and depression: SMD -0.21, 95% CI -0.50 to 0.08; 4 studies, 198 participants; I2 = 0%; moderate-quality evidence) at short- or medium-term follow-up. Seven studies reported on adverse events. We did not pool adverse events due to inconsistency in reporting and measurement. We found no evidence of serious adverse events in the intervention or usual care groups. Minor adverse events, such as neck, back and muscle pain were most commonly reported. No studies reported on overall survival or recurrence-free survival and no studies assessed outcomes at long-term follow-up We found evidence of positive effects of physical activity interventions on the aerobic fitness component of physical fitness (SMD 0.82, 95% CI 0.34 to 1.29; 7 studies, 295; I2 = 68%; low-quality evidence), cancer-related fatigue (MD 2.16, 95% CI 0.18 to 4.15; 6 studies, 230 participants; I2 = 18%; low-quality evidence) and health-related quality of life (SMD 0.36, 95% CI 0.10 to 0.62; 6 studies, 230 participants; I2 = 0%; moderate-quality evidence) at immediate-term follow-up. These positive effects were also observed at short-term follow-up but not medium-term follow-up. Only three studies reported medium-term follow-up for cancer-related fatigue and health-related quality of life.

AUTHORS' CONCLUSIONS

The findings of this review should be interpreted with caution due to the low number of studies included and the quality of the evidence. We are uncertain whether physical activity interventions improve physical function. Physical activity interventions may have no effect on disease-related mental health. Physical activity interventions may be beneficial for aerobic fitness, cancer-related fatigue and health-related quality of life up to six months follow-up. Where reported, adverse events were generally minor. Adequately powered RCTs of high methodological quality with longer-term follow-up are required to assess the effect of physical activity interventions on the disease-related physical and mental health and on survival of people with non-advanced colorectal cancer. Adverse events should be adequately reported.

Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement From the American Heart Association

Cardiovascular disease is a competing cause of death in patients with cancer with early-stage disease. This elevated cardiovascular disease risk is thought to derive from both the direct effects of cancer therapies and the accumulation of risk factors such as hypertension, weight gain, cigarette smoking, and loss of cardiorespiratory fitness. Effective and viable strategies are needed to mitigate cardiovascular disease risk in this population; a multimodal model such as cardiac rehabilitation may be a potential solution. This statement from the American Heart Association provides an overview of the existing knowledge and rationale for the use of cardiac rehabilitation to provide structured exercise and ancillary services to cancer patients and survivors. This document introduces the concept of cardio-oncology rehabilitation, which includes identification of patients with cancer at high risk for cardiac dysfunction and a description of the cardiac rehabilitation infrastructure needed to address the unique exposures and complications related to cancer care. In this statement, we also discuss the need for future research to fully implement a multimodal model of cardiac rehabilitation for patients with cancer and to determine whether reimbursement of these services is clinically warranted.

Synergy Between Licensed Rehabilitation Professionals and Clinical Exercise Physiologists: Optimizing Patient Care for Cancer Rehabilitation

OBJECTIVES

To differentiate between rehabilitation and exercise training and propose how rehabilitation professionals and exercise physiologists can collaborate to optimize cancer survivor care.

DATA SOURCE

Professional organizations and peer-reviewed manuscripts.

CONCLUSION

Both professions offer complementary skillsets that, when integrated, optimize the ability of the cancer care team to implement more effective survivorship care plans. Future models of care must incorporate efficient communications between the cancer rehabilitation program and oncology team, include various reimbursement/payment/funding options, and continuously assess program efficacy.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must be cognizant of physical needs (ie, functional and conditioning status) and cancer-related comorbidities when referring cancer survivors for exercise reconditioning.

A physical activity intervention to improve the quality of life of patients with a stoma: a feasibility study protocol

BACKGROUND

Physical activity (PA) is positively associated with quality of life. People with a stoma are less likely to engage in PA than those without a stoma.

METHODS

In this feasibility intervention study, we will perform the following: (1) Develop a PA intervention for people with a stoma. An Expert Working Group of behavioural scientists, exercise scientists, clinicians and a Patient Advisory Group of people with a bowel stoma will meet with the research team to inform the development of a PA intervention for people with a stoma. A manual of the intervention will be the main output. (2) Explore PA instructors' experiences of delivering the PA intervention. PA instructors will record on paper the number of PA consultations with each patient and a researcher will interview the PA instructors about their experiences of delivering the intervention. (3) Assess the level of patient (bowel cancer or inflammatory bowel disease (IBD) patients with a stoma between 6 weeks and 24 months post-surgery) engagement with the PA intervention and their views on intervention acceptability and usefulness. Patients will keep a PA diary to record daily pedometer recorded step count and type and duration of activities. A researcher will interview patients about their experiences of the PA intervention. (4) Assess screening, eligibility, consent, data completion, loss to follow up, and missing data rates, representativeness of participants and potential treatment effects. A researcher will record on paper all study procedure parameters. Quality of life (stoma-quality of life; Functional Assessment of Cancer Therapy, Short IBD questionnaire), fatigue (FACIT fatigue scale) and PA (accelerometer) will be measured pre- and post-intervention in patients. For IBD patients only, blood will be taken to measure systemic inflammation.

DISCUSSION

We hypothesise that a PA intervention will be an effective means of improving the quality of life of people with a stoma. Before embarking on a full randomised controlled trial to test this hypothesis, a PA intervention needs to be developed and a feasibility study of the proposed PA intervention conducted.

TRIAL REGISTRATION

ISRCTN58613962, Protocol version: 0.1. 14 September 2017.

Smoking, alcohol consumption, diet and physical activity following stoma formation surgery, stoma-related concerns, and desire for lifestyle advice: a United Kingdom survey

BACKGROUND

Adherence to smoking, alcohol consumption, diet and physical activity (PA) guidelines may improve outcomes for people with a stoma. A better understanding of these behaviours following stoma formation surgery and their experiences and attitudes towards receiving lifestyle advice, could help identify specific gaps and inform interventions going forward. The aim of this study was to describe changes in current lifestyle following stoma formation and to explore concerns, desire for lifestyle information, advice and support among people who have or have had a stoma.

METHODS

A sample of adults who currently had or in the past had a stoma for treatment for any medical condition was recruited online through relevant charities and companies, and invited to complete a cross-sectional, online survey. Consenting participants (n = 425) provided demographic information and completed brief, validated questionnaires about their lifestyle, alongside questions around their concerns regarding permanent stoma and experiences of lifestyle information and advice. Responses were summarised using descriptive statistics, and associations between reported concerns about stoma and changes in health behaviours were explored.

RESULTS

Most respondents (93%) still had a stoma at the time of completing the survey. The majority (80%) had not consumed at least 5 portions of fruit and vegetables on the previous day and 20% reported they had not participated in at least 30 min of physical activity on any day in the previous week. Most respondents were non-smokers (84%) and did not exceed recommendations for alcohol intake (60%). Most (56%) felt their PA had decreased following stoma formation. Frequencies of concerns about a permanent stoma were high, and appeared to be associated with reported decreases in PA. Of those reporting nausea, 40% felt their diet had worsened since having their stoma. A large proportion of respondents had not received PA (42%) or dietary (30%) advice, and of these > 90% would have liked guidance.

CONCLUSIONS

Few respondents to this survey were eating the recommended amount of fruit and vegetables, and most reported a decrease in their PA following stoma surgery. Lifestyle advice would be welcomed by this population, which professionals should take into account when addressing stoma- related concerns.

Physical activity referral to cardiac rehabilitation, leisure centre or telephone-delivered consultations in post-surgical people with breast cancer: a mixed methods process evaluation

BACKGROUND

Physical activity (PA) programmes effective under 'research' conditions may not be effective under 'real-world' conditions. A potential solution is to refer patients to existing PA community-based PA services.

METHODS

A process evaluation of referral of post-surgical patients with early-stage breast cancer to cardiac rehabilitation exercise classes, leisure centre with 3-month free leisure centre membership or telephone-delivered PA consultations for 12 weeks. Quantitative data were collected about PA programme uptake and reach, patient engagement with the PA programme, delivery and fidelity and PA dose. Qualitative data were collected about patient experiences of taking part in the PA programmes. Audio-recorded qualitative interviews of participants about the programmes were analysed thematically. Quantitative data were reported descriptively using means and SD.

RESULTS

In Phase I, 30% (n = 20) of eligible patients (n = 20) consented, 85% (n = 17) chose referral to leisure centre, and 15% (n = 3) chose cardiac rehabilitation. In Phase II, 32% (n = 12) consented, 25% (n = 3) chose leisure centre and 75% (n = 9) chose telephone-delivered PA consultations. Walking at light intensity for about an hour was the most common PA. All Phase I participants received an induction by a cardiac rehabilitation physiotherapist or PA specialist from the leisure centre but only 50% of Phase II participants received an induction by a PA specialist from the leisure centre. Four themes were identified from qualitative interviews about programme choice: concerns about physical appearance, travel distance, willingness to socialise and flexibility in relation to doing PA. Four themes were identified about facilitators and barriers for engaging in PA: feeling better, feeling ill, weight management, family and friends.

CONCLUSIONS

The current community-based PA intervention is not yet suitable for a definitive effectiveness randomised controlled trial. Further work is needed to optimise PR programme reach, PA dose and intervention fidelity.

TRIAL REGISTRATION

ISRCTN11183372.

Developing High-Quality Cancer Rehabilitation Programs: A Timely Need

The number of survivors of cancer in the United States, already 14.5 million, is growing with improved cancer treatment and aging of the population. Two-thirds of cancer survivors will be older than age 65 and are likely to enter cancer treatment already deconditioned and with multiple comorbidities. Survivors of cancer face numerous adverse consequences of cancer treatment that add to or exacerbate the effects of existing comorbidities and increase risk of functional decline. Many of these problems are amenable to rehabilitation interventions, but referral to cancer rehabilitation professionals is not a standard part of care. We present an expanded prospective model of surveillance, cancer rehabilitation assessment, and referral efforts using a multidisciplinary team approach. In this model, cancer rehabilitation begins at the time of cancer diagnosis and continues through and beyond cancer treatment. Physical impairments and psychosocial symptoms are assessed and treated, and lifestyle and exercise interventions are provided to optimize functioning, health, and quality of life. We present a stepped-care framework to guide decisions on when, how, and where to refer survivors to cancer rehabilitation specialists depending on safety requirements and needs. This model has the potential to result in early identification of symptoms and impairments, appropriate referral and timely treatment, and, in turn, will better address and minimize both acute and long-term cancer morbidity.

The feasibility and acceptability of trial procedures for a pragmatic randomised controlled trial of a structured physical activity intervention for people diagnosed with colorectal cancer: findings from a pilot trial of cardiac rehabilitation versus usual care (no rehabilitation) with an embedded qualitative study

Background

Pilot and feasibility work is conducted to evaluate the operational feasibility and acceptability of the intervention itself and the feasibility and acceptability of a trials’ protocol design. The Cardiac Rehabilitation In Bowel cancer (CRIB) study was a pilot randomised controlled trial (RCT) of cardiac rehabilitation versus usual care (no rehabilitation) for post-surgical colorectal cancer patients. A key aim of the pilot trial was to test the feasibility and acceptability of the protocol design.

Methods

A pilot RCT with embedded qualitative work was conducted in three sites. Participants were randomly allocated to cardiac rehabilitation or usual care groups. Outcomes used to assess the feasibility and acceptability of key trial parameters were screening, eligibility, consent, randomisation, adverse events, retention, completion, missing data, and intervention adherence rates. Colorectal patients’ and clinicians’ perceptions and experiences of the main trial procedures were explored by interview.

Results

Quantitative study. Three sites were involved. Screening, eligibility, consent, and retention rates were 79 % (156/198), 67 % (133/198), 31 % (41/133), and 93 % (38/41), respectively. Questionnaire completion rates were 97.5 % (40/41), 75 % (31/41), and 61 % (25/41) at baseline, follow-up 1, and follow-up 2, respectively. Sixty-nine percent (40) of accelerometer datasets were collected from participants; 31 % (20) were removed for not meeting wear-time validation.

Qualitative study: Thirty-eight patients and eight clinicians participated. Key themes were benefits for people with colorectal cancer attending cardiac rehabilitation, barriers for people with colorectal cancer attending cardiac rehabilitation, generic versus disease-specific rehabilitation, key concerns about including people with cancer in cardiac rehabilitation, and barriers to involvement in a study about cardiac rehabilitation.

Conclusions

The study highlights where threats to internal and external validity are likely to arise in any future studies of similar structured physical activity interventions for colorectal cancer patients using similar methods being conducted in similar contexts. This study shows that there is likely to be potential recruitment bias and potential imprecision due to sub-optimal completion of outcome measures, missing data, and sub-optimal intervention adherence. Hence, strategies to manage these risks should be developed to stack the odds in favour of conducting successful future trials.

Trial registration

ISRCTN63510637