A randomised controlled trial of a tele-based lifestyle intervention for colorectal cancer survivors ('CanChange'): study protocol

Acceptance and Commitment Therapy Informed Behavioral Health Interventions Delivered by Non-Mental Health Professionals: A Systematic Review

Objectives

Acceptance and Commitment Therapy (ACT) is a third-wave behavioral and cognitive therapy that increases psychological flexibility through mindfulness, acceptance, and value-driven behavior change. ACT has been successfully used to inform a variety of health interventions. Using non-therapists to deliver ACT-based behavioral health interventions offers an opportunity to provide cost efficient and integrated care, particularly among underserved populations experiencing barriers to mental health care, such as inadequate insurance, mental health stigma, and provider shortages. This systematic review aims to: 1) identify ACT-informed behavioral health interventions delivered by laypeople and 2) review the specific characteristics of each intervention including number and duration of sessions, delivery modality, interventionist training, and intervention outcomes.

Methods

Two databases (PubMed and PsycINFO) were systematically searched for relevant literature. To further identify relevant studies, references of included manuscripts were checked, the Association for Contextual Behavioral Science's webpage was examined, and an email was sent to the ACBS Health Special Interest Group listserv. Study abstracts and full texts (in English) were screened, resulting in 23 eligible articles describing 19 different interventions.

Results

A total of 1,781 abstracts were screened, 76 were eligible for full-text review, and 23 were included in a narrative synthesis. There were 19 unique interventions identified and delivered by the following: general healthcare workers (n= 7), trained researchers (n = 5), women/mothers (n= 2), municipal workers (n= 2), and teachers (n = 3). Eleven studies were RCTs and eight utilized alternative study designs. Study quality varied, with two rated as high risk for bias and eight rated to have some concerns. Target populations included clinical and non-clinical samples. There was some consistency in the effects reported in the studies: increases in pain tolerance, acceptance, and identifying and engaging in value driven behavior, improvements in cognitive flexibility, and reductions in psychological distress.

Conclusions

Findings suggest that ACT interventions can be successfully delivered by a variety of laypeople and effectively address psychological distress and increase health behaviors.

Technology-supported Acceptance and Commitment Therapy for chronic health conditions: A systematic review and meta-analysis

Chronic health conditions (CHCs) are common and associated with functional limitations. Acceptance and commitment therapy (ACT) shows promise in improving functioning, quality of life, and distress across several CHCs. The purpose of this study was to conduct a systematic review of technology-supported ACT for CHCs and perform a meta-analysis on functioning and ACT process outcomes. Multiple databases were systematically searched for randomized controlled trials. A total of 20 unique studies with 2,430 randomized participants were included. CHCs addressed in these studies were chronic pain (k = 9), obesity/overweight (k = 4), cancer (k = 3), hearing loss (k = 1), HIV (k = 1), multiple sclerosis (k = 1), and tinnitus (k = 1). Internet and telephone were the most used technology platforms. All studies included therapist contact with considerable heterogeneity between studies. Random effects meta-analyses found medium effect sizes showing technology-supported ACT outperformed comparator groups on measures of function at post-treatment (Hedges' g = -0.49; p = 0.002) and follow-up (Hedges' g = -0.52; p = 0.02), as well as ACT process outcomes at post-treatment (Hedges' g = 0.48; p < 0.001) and follow-up (Hedges' g = 0.44; p < 0.001). Technology-supported ACT shows promise for improving function and ACT process outcomes across a range of CHCs. Recommendations are provided to optimize technology-supported ACT for CHCs. PROSPERO registration number: CRD42020200230.

Application of the Nursing Model Based on Acceptance and Commitment Therapy (ACT) in Improving Mental Health and Quality of Life after Colorectal Cancer Drug Chemotherapy

According to the most current cancer impact statistics, third most commonly diagnosed cancer worldwide is colorectal cancer. Colon cancer, in addition to its physical symptoms, has been linked to mental health issues in patients, according to the study. Dealing with colorectal cancer drug chemotherapy may lead to depression and anxiety in some people. Others are affected by the physical and mental condition of undergoing many therapies at the same time. Throughout the process of diagnosis, a large number of colorectal cancer patients report clinically relevant degrees as well as a decline in overall mental wellness. In the majority of cases, colon cancer patients are cured following therapy, but those who have survived the disease confront a medical range, physical, and challenges in society, for a variety of mental and physical problems such as anxiety and depression. First, meditation therapy is to urge patients to address their issues and feelings instead of dismissing them, but in the dispassionate and unbiased manner that defines the attentive state. Both the patient and the treating professional may benefit from this treatment method, since it appears to be a very effective therapeutic strategy. After colorectal cancer treatment, in studies, it has been demonstrated that ACT improves mental health, and Internet search engines such as Web of Science and Google Scholar as well as Dialnet were utilized to conduct a systematic literature There were 19 articles that fit the criteria. This includes a discussion of the ACT's philosophical and theoretical basis, as well as the treatment itself. On the other hand, the study on ACT for enhancing mental health and quality of life is examined. Several of the available trials had serious flaws, making it impossible to establish reliable conclusions about the effectiveness of ACT for improving mental health and quality of life. The study determined that there is only a small amount of data supporting the use of ACT for improving mental health. The aim of this study is the application of the nursing model on improving the mental health of the colorectal patients. In addition, the limits of the current empirical state of ACT are acknowledged, and the importance of further research is highlighted.

Cruciferous Vegetable Intervention to Prevent Cancer Recurrence in Non-Muscle Invasive Bladder Cancer Survivors: Development using a Systematic Process (Preprint)

Background

Bladder cancer is one of the top 10 most common cancers in the United States. Most bladder cancers (70%-80%) are diagnosed at early stages as non–muscle-invasive bladder cancer (NMIBC), which can be removed surgically. However, 50% to 80% of NMIBC cases recur within 5 years, and 15% to 30% progress with poor survival. Current treatments are limited and expensive. A wealth of preclinical and epidemiological evidence suggests that dietary isothiocyanates in cruciferous vegetables (Cruciferae) could be a novel, noninvasive, and cost-effective strategy to control NMIBC recurrence and progression.

Objective

The aim of this study is to develop a scalable dietary intervention that increases isothiocyanate exposure through Cruciferae intake in NMIBC survivors.

Methods

We worked with a community advisory board (N=8) to identify relevant factors, evidence-based behavior change techniques, and behavioral theory constructs used to increase Cruciferae intake in NMIBC survivors; use the PEN-3 Model focused on incorporating cultural factors salient to the group’s shared experiences to review the intervention components (eg, the saliency of behavioral messages); administer the revised intervention to community partners for their feedback; and refine the intervention.

Results

We developed a multicomponent intervention for NMIBC survivors consisting of a magazine, tracking book, live telephone call script, and interactive voice messages. Entitled POW-R Health: Power to Redefine Your Health, the intervention incorporated findings from our adaptation process to ensure saliency to NMIBC survivors.

Conclusions

This is the first evidence-based, theoretically grounded dietary intervention developed to reduce bladder cancer recurrence in NMIBC survivors using a systematic process for community adaptation. This study provides a model for others who aim to develop behavioral, community-relevant interventions for cancer prevention and control with the overall goal of wide-scale implementation and dissemination.

Effectiveness of psychosocial interventions for posttraumatic growth in patients with cancer: A meta-analysis of randomized controlled trials

PURPOSE

To evaluate the effectiveness of psychosocial interventions for posttraumatic growth in patients with cancer.

METHOD

A systematic literature search was performed, and relevant studies published prior to January 8, 2020, were retrieved from MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trails, CINAHL, and PsycINFO. Two reviewers independently assessed the eligibility of each study and extracted the data. The Cochrane risk-of-bias tool was utilized to assess the quality of the studies. Review Manager (Version 5.3) was used to analyse the data. The posttraumatic growth scores were calculated using the standard mean difference (SMD) and 95% confidence intervals (CIs).

RESULTS

Fifteen randomized controlled trials published between 2000 and 2019 were included. Most of the studies had a moderate risk of bias due to low methodological quality. The meta-analysis indicated that the PTG scores in the experimental groups were higher than those in the control groups (SMD = 0.42, 95% CI: 0.26-0.57, P < 0.00001). The most effective and commonly used method was mindfulness-based interventions (SMD = 0.55, 95% CI: 0.15-0.95, P = 0.007). Subgroup analysis showed that the effects of psychosocial interventions on breast cancer patients are greater than the effects on other types of cancer patients (SMD = 0.72, 95% CI: 0.44-0.99, P < 0.00001).

CONCLUSION

Psychosocial interventions for cancer patients are effective in facilitating posttraumatic growth. The most commonly used and effective methods are mindfulness-based interventions. More large well-designed randomized controlled trials are needed to identify the effectiveness of psychosocial interventions for posttraumatic growth in patients with cancer.

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.

The effectiveness of distance‐based interventions for smoking cessation and alcohol moderation among cancer survivors: A meta‐analysis

OBJECTIVE

The objective of this study is to evaluate current evidence for the effectiveness of distance-based interventions to support smoking cessation (SC) or alcohol moderation (AM) among cancer survivors. Secondary, differences in effectiveness are explored regarding multibehaviour interventions versus single-behaviour interventions targeting SC or AM only.

METHODS

A systematic search of PubMed, PsycINFO, Web of Science, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials was conducted. Intervention studies with and without control groups and randomized controlled trials were included. Random effects meta-analyses were conducted for the main outcomes: SC and AM rates at the follow-up closest to 6 months. Using subgroup analyses and meta-regression, effectiveness of single-behaviour versus multibehaviour interventions was evaluated.

RESULTS

A total of 17 studies with 3796 participants; nine studies on SC only, eight studies on multibehaviour interventions including an SC or AM module, and no studies on AM only were included. All studies had at least some concerns regarding bias. Distance-based SC interventions led to higher cessation rates than control conditions (10 studies, odds ratio [OR] = 1.56; 95% CI, 1.13-2.15, P = .007). Single-behaviour SC interventions reduced smoking rates compared with baseline (risk difference [RD] = 0.29; 95% CI, 0.19-0.39, P < .0001), but multibehaviour interventions did not (RD = 0.13; 95% CI, -0.05 to 0.31, P = 0.15). There was insufficient evidence that distance-based multibehaviour interventions reduced alcohol use compared with controls (three studies, standardized mean difference [SMD] = 0.12; 95% CI, -0.08 to 0.31, P = .24).

CONCLUSIONS

Distance-based SC interventions are effective in supporting SC among cancer survivors. Single-behaviour SC interventions appear more effective than multibehaviour interventions. No evidence was found for the effectiveness of distance-based AM interventions for cancer survivors.

Dietary interventions for adult cancer survivors

BACKGROUND

International dietary recommendations include guidance on healthy eating and weight management for people who have survived cancer; however dietary interventions are not provided routinely for people living beyond cancer.

OBJECTIVES

To assess the effects of dietary interventions for adult cancer survivors on morbidity and mortality, changes in dietary behaviour, body composition, health-related quality of life, and clinical measurements.

SEARCH METHODS

We ran searches on 18 September 2019 and searched the Cochrane Central Register of Controlled trials (CENTRAL), in the Cochrane Library; MEDLINE via Ovid; Embase via Ovid; the Allied and Complementary Medicine Database (AMED); the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and the Database of Abstracts of Reviews of Effects (DARE). We searched other resources including reference lists of retrieved articles, other reviews on the topic, the International Trials Registry for ongoing trials, metaRegister, Physicians Data Query, and appropriate websites for ongoing trials. We searched conference abstracts and WorldCat for dissertations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that recruited people following a cancer diagnosis. The intervention was any dietary advice provided by any method including group sessions, telephone instruction, written materials, or a web-based approach. We included comparisons that could be usual care or written information, and outcomes measured included overall survival, morbidities, secondary malignancies, dietary changes, anthropometry, quality of life (QoL), and biochemistry.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two people independently assessed titles and full-text articles, extracted data, and assessed risk of bias. For analysis, we used a random-effects statistical model for all meta-analyses, and the GRADE approach to rate the certainty of evidence, considering limitations, indirectness, inconsistencies, imprecision, and bias.

MAIN RESULTS

We included 25 RCTs involving 7259 participants including 977 (13.5%) men and 6282 (86.5%) women. Mean age reported ranged from 52.6 to 71 years, and range of age of included participants was 23 to 85 years. The trials reported 27 comparisons and included participants who had survived breast cancer (17 trials), colorectal cancer (2 trials), gynaecological cancer (1 trial), and cancer at mixed sites (5 trials). For overall survival, dietary intervention and control groups showed little or no difference in risk of mortality (hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.77 to 1.23; 1 study; 3107 participants; low-certainty evidence). For secondary malignancies, dietary interventions versus control trials reported little or no difference (risk ratio (RR) 0.99, 95% CI 0.84 to 1.15; 1 study; 3107 participants; low-certainty evidence). Co-morbidities were not measured in any included trials. Subsequent outcomes reported after 12 months found that dietary interventions versus control probably make little or no difference in energy intake at 12 months (mean difference (MD) -59.13 kcal, 95% CI -159.05 to 37.79; 5 studies; 3283 participants; moderate-certainty evidence). Dietary interventions versus control probably led to slight increases in fruit and vegetable servings (MD 0.41 servings, 95% CI 0.10 to 0.71; 5 studies; 834 participants; moderate-certainty evidence); mixed results for fibre intake overall (MD 5.12 g, 95% CI 0.66 to 10.9; 2 studies; 3127 participants; very low-certainty evidence); and likely improvement in Diet Quality Index (MD 3.46, 95% CI 1.54 to 5.38; 747 participants; moderate-certainty evidence). For anthropometry, dietary intervention versus control probably led to a slightly decreased body mass index (BMI) (MD -0.79 kg/m², 95% CI -1.50 to -0.07; 4 studies; 777 participants; moderate-certainty evidence). Dietary interventions versus control probably had little or no effect on waist-to-hip ratio (MD -0.01, 95% CI -0.04 to 0.02; 2 studies; 106 participants; low-certainty evidence). For QoL, there were mixed results; several different quality assessment tools were used and evidence was of low to very low-certainty. No adverse events were reported in any of the included studies.

AUTHORS' CONCLUSIONS

Evidence demonstrated little effects of dietary interventions on overall mortality and secondary cancers. For comorbidities, no evidence was identified. For nutritional outcomes, there was probably little or no effect on energy intake, although probably a slight increase in fruit and vegetable intake and Diet Quality Index. Results were mixed for fibre. For anthropometry, there was probably a slight decrease in body mass index (BMI) but probably little or no effect on waist-to-hip ratio. For QoL, results were highly varied. Additional high-quality research is needed to examine the effects of dietary interventions for different cancer sites, and to evaluate important outcomes including comorbidities and body composition. Evidence on new technologies used to deliver dietary interventions was limited.

Promoting Healthy Eating and Physical Activity Behaviors: A Systematic Review of Multiple Health Behavior Change Interventions Among Cancer Survivors

Multiple health behavior change (MHBC) interventions have great potential for enhancing health and well-being following cancer diagnosis and treatment. However, the characteristics and effects of MHBC interventions remain elusive for cancer survivors. The main purpose of this study was to evaluate the effectiveness of MHBC interventions on healthy eating and physical activity behaviors among cancer survivors. A secondary aim was to examine the effect of using a simultaneous and sequential design approach to MHBC (ie, changing both behaviors at the same time or one after the other). Randomized controlled trials reporting the impact of a MHBC intervention on both healthy eating and physical activity behaviors among cancer survivors were retrieved from MEDLINE, Cochrane Library, and PsycINFO. A total of 27 MHBC interventions were identified; most (92.6%) were designed to promote simultaneous change in both behaviors and assessed end-of-treatment effect among breast cancer survivors. MHBC interventions led by nurses or multidisciplinary teams showed the most compelling evidence for small to moderate improvement in both behaviors, with interventions that lasted ≥17 weeks more likely to improve both behaviors. This study identifies research priorities and provides preliminary evidence for clinical decision making and advancements in MHBC intervention design and delivery for clinical oncology.

The Use of Acceptance and Commitment Therapy in Oncology Settings: A Narrative Review

Various psychotherapeutic approaches have been developed to address the psychosocial stressors and distress associated with cancer diagnosis and treatment. One such approach, Acceptance and Commitment Therapy (ACT), may be particularly well suited to people with cancer as it offers a model of healthy adaptation to difficult circumstances. This paper provides a description and theoretical rationale for using ACT in psychosocial oncology care that emphasizes emotional distress and cancer-related pain and provides a narrative review of the current state of evidence for this setting. Six studies met eligibility criteria for inclusion in the review. The research designs included one case study, three pre-post cohort studies, and two randomized controlled trials. Cancer diagnoses of patients included breast cancer, ovarian cancer, colorectal cancer, and mixed cancer populations at various stages of disease progression or recovery. ACT interventions demonstrated significant improvements in symptoms including quality of life and psychological flexibility as well as reductions in symptoms including distress, emotional disturbances, physical pain, and traumatic responses. Overall, although there is limited published research currently available, there is some evidence to support ACT as an effective psychotherapeutic approach for cancer patients. Further research is needed for different cancer populations across the illness trajectory. Barriers to implementation are discussed.

Preventing weight gain in African American breast cancer survivors using smart scales and activity trackers: a randomized controlled pilot study

PURPOSE

This study evaluated the feasibility and preliminary efficacy of two 6-month, self-regulation interventions that focused on daily self-weighing (DSW) and used objective monitoring and tailored feedback about weight (±activity), to prevent weight gain among African American breast cancer survivors.

METHODS

Participants (n = 35) were randomized to an intervention + activity monitoring (INT+), intervention (INT), or control (CON) group. Interventions included a wireless scale (±activity tracker) that transmitted objective data to a mobile app/website, emailed lessons, and tailored feedback based on objective weight (±activity data). Participants completed in-person and online assessments at baseline, 3 months, and 6 months.

RESULTS

Ninety-four percent of participants completed assessments at 3 months, and 97 % at 6 months. Median (IQR) weight change after 6 months was -0.9 % (-4.4-0.1) in the INT+ (p = 0.075; p = 0.067 vs. CON) and -0.2 % (-4.2-1.3) in the INT groups (p = 0.463; p = 0.357 vs. CON), versus a 0.2 % (-0.7-1.7) gain in the CON group. The proportion of INT+, INT, and CON participants that were at or below baseline weight was 72.7, 53.8, and 45.5 %, respectively (effect sizes d = 0.64, d = 0.18). Most INT+ participants weighed and wore trackers ≥5 days/week (INT+, 81.9 % vs. INT, 38.5 % vs. CON, 0 %; p < 0.0005; INT+, 72.7 %). Both intervention groups perceived DSW as positive, and 100 % would recommend the program to other breast cancer survivors.

CONCLUSION

An intervention focused on DSW as a self-monitoring strategy shows promise for preventing weight gain in breast cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Daily self-monitoring of weight and activity may be a feasible and accessible approach to promote weight gain prevention in breast cancer survivors.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02030353.

The use of cardiac rehabilitation services to aid the recovery of patients with bowel cancer: a pilot randomised controlled trial with embedded feasibility study

Background

Colorectal cancer (CRC) survivors are not meeting the recommended physical activity levels associated with improving their chances of survival and quality of life. Rehabilitation could address this problem.

Objectives

The aims of the Cardiac Rehabilitation In Bowel cancer study were to assess whether or not cardiac rehabilitation is a feasible and acceptable model to aid the recovery of people with CRC and to test the feasibility and acceptability of the protocol design.

Design

Intervention testing and feasibility work (phase 1) and a pilot randomised controlled trial with embedded qualitative study (phase 2), supplemented with an economic evaluation. Randomisation was to cardiac rehabilitation or usual care. Outcomes were differences in objective measures of physical activity and sedentary behaviour, self-reported measures of quality of life, anxiety, depression and fatigue. Qualitative work involved patients and clinicians from both cancer and cardiac specialties.

Setting

Three colorectal cancer wards and three cardiac rehabilitation facilities.

Participants

Inclusion criteria were those who were aged > 18 years, had primary CRC and were post surgery.

Results

Phase 1 (single site) – of 34 patient admissions, 24 (70%) were eligible and 4 (17%) participated in cardiac rehabilitation. Sixteen clinicians participated in an interview/focus group. Modifications to trial procedures were made for further testing in phase 2. Additionally, 20 clinicians in all three sites were trained in cancer and exercise, rating it as excellent. Phase 2 (three sites) – screening, eligibility, consent and retention rates were 156 (79%), 133 (67%), 41 (31%) and 38 (93%), respectively. Questionnaire completion rates were 40 (97.5%), 31 (75%) and 25 (61%) at baseline, follow-up 1 and follow-up 2, respectively. Forty (69%) accelerometer data sets were analysed; 20 (31%) were removed owing to invalid data.

Qualitative study

CRC and cardiac patients and clinicians were interviewed. Key themes were benefits and barriers for people with CRC attending cardiac rehabilitation; generic versus disease-specific rehabilitation; key concerns of the intervention; and barriers to participation (CRC participants only).

Economic evaluation

The average out-of-pocket expenses of attending cardiac rehabilitation were £50. The costs of cardiac rehabilitation for people with cancer are highly dependent on whether it involves accommodating additional patients in an already existing service or setting up a completely new service.

Limitations and conclusions

The main limitation is that this is a small feasibility and pilot study. The main novel finding is that cardiac rehabilitation for cancer and cardiac patients together is feasible and acceptable, thereby challenging disease-specific rehabilitation models.

Future work

This study highlighted important challenges to doing a full-scale trial of cardiac rehabilitation but does not, we believe, provide sufficient evidence to reject the possibility of such a future trial. We recommend that any future trial must specifically address the challenges identified in this study, such as suboptimal consent, completion, missing data and intervention adherence rates and recruitment bias, and that an internal pilot trial be conducted. This should have clear ‘stop–proceed’ rules that are formally reviewed before proceeding to the full-scale trial.

Trial registration

Current Controlled Trials ISRCTN63510637.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 4, No. 24. See the NIHR Journals Library website for further project information.

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

OBJECTIVES

(1) Assess whether cardiac rehabilitation (CR) is a feasible and acceptable model of rehabilitation for postsurgical colorectal cancer (CRC) survivors, (2) evaluate trial procedures. This article reports the results of the first objective.

DESIGN AND SETTING

A pragmatic pilot randomised controlled trial with embedded qualitative study was conducted in 3 UK hospitals with CR facilities. Descriptive statistics were used to summarise trial parameters indicative of intervention feasibility and acceptability. Interviews and focus groups were conducted and data analysed thematically.

PARTICIPANTS

People with CRC were considered for inclusion in the trial if they were ≥ 18 years old, diagnosed with primary CRC and in the recovery period postsurgery (they could still be receiving adjuvant therapy). 31% (n=41) of all eligible CRC survivors consented to participate in the trial. 22 of these CRC survivors, and 8 people with cardiovascular disease (CVD), 5 CRC nurses and 6 CR clinicians participated in the qualitative study.

INTERVENTION

Referral of postsurgical CRC survivors to weekly CR exercise classes and information sessions. Classes included CRC survivors and people with CVD. CR nurses and physiotherapists were given training about cancer and exercise.

RESULTS

Barriers to CR were protracted recoveries from surgery, ongoing treatments and poor mobility. No adverse events were reported during the trial, suggesting that CR is safe. 62% of participants completed the intervention as per protocol and had high levels of attendance. 20 health professionals attended the cancer and exercise training course, rating it as excellent. Participants perceived that CR increased CRC survivors' confidence and motivation to exercise, and offered peer support. CR professionals were concerned about CR capacity to accommodate cancer survivors and their ability to provide psychosocial support to this group of patients.

CONCLUSIONS

CR is feasible and acceptable for postsurgical CRC survivors. A large-scale effectiveness trial of the intervention should be conducted.

TRIAL REGISTRATION NUMBER

ISRCTN63510637.

Effects of a multiple health behavior change intervention for colorectal cancer survivors on psychosocial outcomes and quality of life: a randomized controlled trial

BACKGROUND

Multiple health behavior change can ameliorate adverse effects of cancer.

PURPOSE

The purpose of this study was to determine the effects of a multiple health behavior change intervention (CanChange) for colorectal cancer survivors on psychosocial outcomes and quality of life.

METHODS

A total of 410 colorectal cancer survivors were randomized to a 6-month telephone-based health coaching intervention (11 sessions using acceptance and commitment therapy strategies focusing on physical activity, weight management, diet, alcohol, and smoking) or usual care. Posttraumatic growth, spirituality, acceptance, mindfulness, distress, and quality of life were assessed at baseline, 6 and 12 months.

RESULTS

Significant intervention effects were observed for posttraumatic growth at 6 (7.5, p < 0.001) and 12 months (4.1, p = 0.033), spirituality at 6 months (1.8, p = 0.011), acceptance at 6 months (0.2, p = 0.005), and quality of life at 6 (0.8, p = 0.049) and 12 months (0.9, p = 0.037).

CONCLUSIONS

The intervention improved psychosocial outcomes and quality of life (physical well-being) at 6 months with most effects still present at 12 months. (

TRIAL REGISTRATION NUMBER

ACTRN12608000399392).

Role of physical activity and diet after colorectal cancer diagnosis

This review summarizes the evidence regarding physical activity and diet after colorectal cancer diagnosis in relation to quality of life, disease recurrence, and survival. There have been extensive reports on adiposity, inactivity, and certain diets, particularly those high in red and processed meats, and increased risk of colorectal cancer. Only in the past decade have data emerged on how such lifestyle factors are associated with outcomes in colorectal cancer survivors. Prospective observational studies have consistently reported that physical activity after colorectal cancer diagnosis reduces mortality. A meta-analysis estimated that each 15 metabolic equivalent task-hour per week increase in physical activity after colorectal cancer diagnosis was associated with a 38% lower risk of mortality. No randomized controlled trials have been completed to confirm that physical activity lowers risk of mortality among colorectal cancer survivors; however, trials have shown that physical activity, including structured exercise, is safe for colorectal cancer survivors (localized to metastatic stage, during and after treatment) and improves cardiorespiratory fitness and physical function. In addition, prospective observational studies have suggested that a Western dietary pattern, high carbohydrate intake, and consuming sugar-sweetened beverages after diagnosis may increase risk of colorectal cancer recurrence and mortality, but these data are limited to single analyses from one of two US cohorts. Additional data from prospective studies and randomized controlled trials are needed. Nonetheless, on the basis of the available evidence, it is reasonable to counsel colorectal cancer survivors to engage in regular physical activity and limit consumption of refined carbohydrates, red and processed meats, and sugar-sweetened beverages.

Telephone, print, and Web-based interventions for physical activity, diet, and weight control among cancer survivors: a systematic review

PURPOSE

Broad-reach (non-face-to-face) modalities offer an accessible and cost-effective means to provide behavior change programs in diverse and growing cancer survivor populations. The purpose of this systematic review is to evaluate the efficacy of physical activity, dietary, and/or weight control interventions for cancer survivors in which telephone, short-message service, print, and/or Web is the primary method of delivery.

METHODS

A structured search of PubMed, Embase, Web of Science, CINAHL, and CENTRAL (May 2013) was conducted. Included studies focused and reported on physical activity (PA) and dietary change and/or weight control in adult cancer survivors, delivered at least 50% of intervention contacts by broad-reach modality and included a control group. Study design, intervention features, and behavioral/weight outcomes were extracted, tabulated, and summarized.

RESULTS

Twenty-seven studies were included; 22 telephone, three Web, and two print. Sixteen studies targeted PA, two diet, and nine targeted multiple behaviors. Most studies (18/27) targeted a single survivor group, namely breast cancer (n = 12). Nineteen of 27 studies found evidence for initiation of behavior change, with only eight reporting on maintenance and one on cost-effectiveness.

CONCLUSIONS

This review provides support for broad-reach modalities, particularly the telephone, in the delivery of lifestyle interventions to cancer survivors. Future research should evaluate (1) newer technologies (i.e., SMS and mobile phone applications), (2) interventions for diverse cancer survivors and those targeting multiple behaviors, (3) long-term outcomes, and 4) cost-effectiveness.

IMPLICATIONS FOR CANCER SURVIVORS

Broad-reach lifestyle interventions are effective, with further research needed to evaluate their generalizability and integration into cancer care.

Rehabilitation model program for seriously ill patients

<b>Background</b><br /> Patients receiving cancer treatment start lifestyle changes mostly at the end of the treatment during the rehabilitation period. Most often, the first step is a dietary change and physical exercises built into the daily routine. Patients who do this in groups led by qualified therapists and based on professional counseling can build more effective and more permanent changes into their life.<br /> To develop a complex rehabilitation program which, in the short term, aims to familiarize patients with a lifestyle which harmonizes the physical, mental, spiritual and social spheres of life and, in the long term, to build it into their everyday life in order to ameliorate the physical and mental state and reduce the psychological symptoms and the isolation of patients. The physical component focuses on diet and exercise. The psycho-social-spiritual support focuses on discovering inner sources of strength, developing active coping mechanisms and helping to achieve more open communication.<br /> <br /> <b>Participants and procedure</b><br /> In February and March 2011, 8 patients treated for malignant tumors participated in the model program. The components of the model program were psychotherapy, physiotherapy, cancer consultation, nutrition counseling, creative activities and walking.<br /> <br /> <b>Results</b><br /> During the period of the model program the isolation of the patients decreased and their social support and ability of coping with the illness ameliorated. They reported an ease in anxiety and depression in their everyday activities. According to feedback, their communication with each other, with the staff and with their relatives became more open. Altogether this had advantageous effects on the functioning of the ward and the mood of the staff.<br /> <br /> <b>Conclusions</b><br /> The rehabilitation program confirmed that beside individual psycho-social support, beneficial and economic psycho-social support can be provided for the patients in group form along with the most effective assignment of the resources of the staff.

Effects of a telephone-delivered multiple health behavior change intervention (CanChange) on health and behavioral outcomes in survivors of colorectal cancer: a randomized controlled trial

PURPOSE

Colorectal cancer survivors are at risk for poor health outcomes because of unhealthy lifestyles, but few studies have developed translatable health behavior change interventions. This study aimed to determine the effects of a telephone-delivered multiple health behavior change intervention (CanChange) on health and behavioral outcomes among colorectal cancer survivors.

METHODS

In this two-group randomized controlled trial, 410 colorectal cancer survivors were randomly assigned to the health coaching intervention (11 theory-based telephone-delivered health coaching sessions delivered over 6 months focusing on physical activity, weight management, dietary habits, alcohol, and smoking) or usual care. Assessment of primary (ie, physical activity [Godin Leisure Time Index], health-related quality of life [HRQoL; Short Form-36], and cancer-related fatigue [Functional Assessment of Chronic Illness Therapy Fatigue Scale]) and secondary outcomes (ie, body mass index [kg/m(2)], diet and alcohol intake [Food Frequency Questionnaire], and smoking) were conducted at baseline and 6 and 12 months.

RESULTS

At 12 months, significant intervention effects were observed for moderate physical activity (28.5 minutes; P = .003), body mass index (-0.9 kg/m(2); P = .001), energy from total fat (-7.0%; P = .006), and energy from saturated fat (-2.8%; P = .016). A significant intervention effect was reported for vegetable intake (0.4 servings per day; P = .001) at 6 months. No significant group differences were found at 6 or 12 months for HRQoL, cancer-related fatigue, fruit, fiber, or alcohol intake, or smoking.

CONCLUSION

The CanChange intervention was effective for improving physical activity, dietary habits, and body mass index in colorectal cancer survivors. The intervention is translatable through existing telephone cancer support and information services in Australia and other countries.

Can colorectal cancer survivors recall their medications and doctor visits reliably?

Background

The evidence on the agreement between self-reported health resource use and administrative records is mixed and no gold standard exists. The objective of this study was to assess self-reported general practitioner (GP) and specialist doctor visits, as well as medication use via telephone interview against national insurance administrative data for colorectal cancer survivors.

Methods

In a sample of 76 adults recently diagnosed with colorectal cancer, data was abstracted from telephone survey items on GP visits, specialist visits and medication use over the previous six months and compared with data on the same individuals from administrative data. Intraclass correlation coefficients (ICC) were used to assess the reliability of frequency of visits and kappa statistics were derived for four broad categories of medicines used for gastrointestinal conditions, cardiovascular disease, psychological conditions and chronic obstructive pulmonary disease. Logistic regression was undertaken to assess factors associated with agreement (yes/no) between the two data sources for doctors’ visits.

Results

Good agreement was found for GP visits (ICC 0.62, 95%CI: 0.38, 0.86) and specialist visits (ICC 0.73, 95%CI: 0.56, 0.91) across the two data sources. When costs were assigned to frequencies, mean costs for the two methods were not significantly different over six months. Over-reporting was more common among men and participants with frequent doctor encounters. Large discrepancies between self-reports and administration records were found for broad types of medications used (44% agreement, kappa 0.13).

Conclusion

Self-reported frequency of doctor’s visits using telephone interviews may be a reasonable substitute for administratively recorded data however, medication use by self-report appears to be unreliable. Administrative records are preferable to self-report for health service use in colorectal cancer survivors with high and complex service needs.

CanPrevent: a telephone-delivered intervention to reduce multiple behavioural risk factors for colorectal cancer

BACKGROUND

This pilot study aimed to test the acceptability and short-term effectiveness of a telephone-delivered multiple health behaviour change intervention for relatives of colorectal cancer survivors.

METHODS

A community-based sample of 22 first-degree relatives of colorectal cancer survivors were recruited via a media release. Data were collected at baseline and at six weeks (post-intervention). Outcome measures included health behaviours (physical activity, television viewing, diet, alcohol, body mass index, waist circumference and smoking), health-related quality of life (Short Form-36) and perceived colorectal cancer risk. Intervention satisfaction levels were also measured. The intervention included six telephone health coaching sessions, a participant handbook and a pedometer. It focused on behavioural risk factors for colorectal cancer [physical activity, diet (red and processed meat consumption, fruit and vegetable intake), alcohol, weight management and smoking], and colorectal cancer risk.

RESULTS

From baseline to six weeks, improvements were observed for minutes moderate-vigorous physical activity (150.7 minutes), processed meat intake (-1.2 serves/week), vegetable intake (1 serve/day), alcohol intake (-0.4 standard drinks/day), body mass index (-1.4 kg/m2), and waist circumference (-5.1 cm). Improvements were also observed for physical (3.3) and mental (4.4) health-related quality of life. Further, compared with baseline, participants were more likely to meet Australian recommendations post-intervention for: moderate-vigorous physical activity (27.3 vs 59.1%); fruit intake (68.2 vs 81.8%); vegetable intake (4.6 vs 18.2%); alcohol consumption (59.1 vs 72.7%); body mass index (31.8 vs 45.5%) and waist circumference (18.2 vs 27.3%). At six weeks participants were more likely to believe a diagnosis of CRC was related to family history, and there was a decrease in their perceived risk of developing CRC in their lifetime following participation in CanPrevent. The intervention retention rate was 100%, participants reported that it was highly acceptable and they would recommend it to others at risk of colorectal cancer.

CONCLUSIONS

Positive behaviour change achieved through this intervention approach has the potential to impact on the progression of CRC and other cancers or chronic diseases. A large scale randomised controlled trial is required to confirm the positive results of this acceptability and short-term effectiveness study.

TRIAL REGISTRATION

ACTRN12612000516886.

Information needs across the colorectal cancer care continuum: scoping the literature

Because cancer care requires a multifaceted approach, providing useful and timely information to people with colorectal cancer may be fragmented and inconsistent. Our interest was in examining what has and has not captured the attention of researchers speaking to the information needs of people with colorectal cancer. We followed Arksey and O'Malley's framework for the methodology of scoping review. Focusing solely on colorectal cancer, we analysed 239 articles to get a picture of which information needs and sources of information, as well as the timing of providing information, were attended to. Treatment-related information received the most mentions (26%). Healthcare professionals (49%) were mentioned as the most likely source of information. Among articles focused on one stage of the care continuum, post-treatment (survivorship) received the most attention (16%). Only 27% of the articles consulted people with colorectal cancer and few attended to diet/nutrition and bowel management. This study examined the numerical representation of issues to which researchers attend, not the quality of the mentions. We ponder, however, on the relationship between the in/frequency of mentions and the actual information needs of people with colorectal cancer as well as the availability, sources and timing of information.

Living with prostate cancer: randomised controlled trial of a multimodal supportive care intervention for men with prostate cancer

Background

Prostate cancer is the most common male cancer in developed countries and diagnosis and treatment carries with it substantial morbidity and related unmet supportive care needs. These difficulties may be amplified by physical inactivity and obesity. We propose to apply a multimodal intervention approach that targets both unmet supportive care needs and physical activity.

Methods/design

A two arm randomised controlled trial will compare usual care to a multimodal supportive care intervention "Living with Prostate Cancer" that will combine self-management with tele-based group peer support. A series of previously validated and reliable self-report measures will be administered to men at four time points: baseline/recruitment (when men are approximately 3-6 months post-diagnosis) and at 3, 6, and 12 months after recruitment and intervention commencement. Social constraints, social support, self-efficacy, group cohesion and therapeutic alliance will be included as potential moderators/mediators of intervention effect. Primary outcomes are unmet supportive care needs and physical activity levels. Secondary outcomes are domain-specific and health-related quality of life (QoL); psychological distress; benefit finding; body mass index and waist circumference. Disease variables (e.g. cancer grade, stage) will be assessed through medical and cancer registry records. An economic evaluation will be conducted alongside the randomised trial.

Discussion

This study will address a critical but as yet unanswered research question: to identify a population-based way to reduce unmet supportive care needs; promote regular physical activity; and improve disease-specific and health-related QoL for prostate cancer survivors. The study will also determine the cost-effectiveness of the intervention.

Trial Registration

ACTRN12611000392965

Colorectal cancer survivorship: movement matters

Colorectal cancer survivorship begins at diagnosis and continues throughout life. After diagnosis, survivors face the possibility of second cancers, long-term effects of cancer treatment, and comorbid conditions. Interventions that can provide primary, secondary, and tertiary prevention in this population are important. Physical activity has been shown to decrease colon cancer incidence and recurrence risk as well as improve quality of life and noncancer health outcomes including cardiovascular fitness in colon cancer survivors. The data are less robust for rectal cancer incidence and recurrence, although improvements in quality of life and health outcomes in rectal cancer survivors are also seen. Potential mechanisms for this benefit may occur through inflammatory or insulin-like growth factor pathways. The issues of colorectal cancer survivorship and the impact of physical activity on these issues are reviewed, with discussion of possible biologic mechanisms, barriers to physical activity intervention studies, and future research directions for physical activity in this burgeoning survivor population.

Lifestyle factors associated concurrently and prospectively with co-morbid cardiovascular disease in a population-based cohort of colorectal cancer survivors

AIMS

To assess self-reported lifetime prevalence of cardiovascular disease (CVD) among colorectal cancer survivors, and examine the cross-sectional and prospective associations of lifestyle factors with co-morbid CVD.

METHODS

Colorectal cancer survivors were recruited (n=1966). Data were collected at approximately 5, 12, 24 and 36 months post-diagnosis. Cross-sectional findings included six CVD categories (hypercholesterolaemia, hypertension, diabetes, heart failure, kidney disease and ischaemic heart disease (IHD)) at 5 months post-diagnosis. Longitudinal outcomes included the probability of developing (de novo) co-morbid CVD by 36 months post-diagnosis. Lifestyle factors included body mass index, physical activity, television (TV) viewing, alcohol consumption and smoking.

RESULTS

Co-morbid CVD prevalence at 5 months post-diagnosis was 59%, and 16% of participants with no known CVD at the baseline reported de novo CVD by 36 months. Obesity at the baseline predicted de novo hypertension (odds ratio [OR]=2.20, 95% confidence intervals [CI]=1.09, 4.45) and de novo diabetes (OR=6.55, 95% CI=2.19, 19.53). Participants watching >4h of TV/d at the baseline (compared with <2h/d) were more likely to develop ischaemic heart disease by 36 months (OR=5.51, 95% CI=1.86, 16.34).

CONCLUSION

Overweight colorectal cancer survivors were more likely to suffer from co-morbid CVD. Interventions focusing on weight management and other modifiable lifestyle factors may reduce functional decline and improve survival.

The effects of obesity and obesity-related conditions on colorectal cancer prognosis

BACKGROUND

Colorectal cancer is the second-leading cause of cancer death in the United States among men and women combined. Refinements in screening, staging, and treatment strategies have improved survival from this disease, with over 65% of patients diagnosed with colorectal cancer surviving over 5 years after diagnosis. In the prognosis of colorectal cancer, clinicopathological factors are important. However, modifiable prognostic factors are emerging as significant contributors to cancer outcomes, including obesity and obesity-related inflammation and metabolic conditions.

METHODS

This report reviews the literature on obesity and obesity-related inflammation and metabolic disturbances and colorectal cancer outcomes (recurrence, disease-free survival, and/or mortality). A PubMed search was conducted of all English-language papers published between August 2003 and 2009 and cited in MEDLINE.

RESULTS

Primary research papers were reviewed for colorectal cancer outcomes related to obesity, inflammation, or metabolic conditions. An association between body size and colorectal cancer recurrence and possibly survival was found; however, reports have been inconsistent. These inconsistent findings may be due to the complex interaction between adiposity, physical inactivity, and dietary intake. Circulating prognostic markers such as C-reactive protein, insulin-like growth factor, and insulin, alone or in combination, have been associated with prognosis in observational studies and should be evaluated in randomized trials and considered for incorporation into surveillance.

CONCLUSIONS

The literature suggests that obesity and obesity-related inflammation and metabolic conditions contribute to the prognosis of colorectal cancer; however, comprehensive large scale trials are needed. Interventions to reduce weight and control inflammation and metabolic conditions, such as diabetes, need to be evaluated and rapidly translated to behavior guidelines for patients.