Connecting people with cancer to physical activity and exercise programs: a pathway to create accessibility and engagement

Exercise in cancer patients: assistance levels and referral pathways-a position statement from the Spanish Society of Medical Oncology

There is growing evidence about how physical activity can improve cancer care. Unfortunately, exercise is still not widely prescribed to oncology patients, despite the benefit it brings. For this to occur, it is necessary for a multidisciplinary approach involving different types of healthcare professionals, given that each treatment be tailored for each single case. Besides incorporating appropriate infrastructures and referral pathways, we need to integrate exercise into healthcare practice, which ameliorates patients' quality of life and treatment side effects. From the Spanish Society of Medical Oncology (SEOM), and through the Exercise and Cancer Working Group, we indicate considerations, analyze patient care scenarios, and propose a referral pathway algorithm for exercise prescription, taking in account the patient's needs. In later sections of this paper, we describe how this algorithm could be implemented, and how the exercise programs should be built, including the physical activity contents, the settings, and the delivery mode. We conclude that professionals, infrastructures, and organizations should be available at every assistance level to create programs providing adequate exercise training for cancer patients.

Exploring the reasons for wanting a peer partner to be physically active among women living with and beyond a cancer diagnosis: a content analysis

BACKGROUND

Initiating and maintaining exercise is challenging for women during and post-cancer treatment. Adopting a peer partner model to provide social support to be active may contribute to lasting behaviour change of both partners. Despite this, finding a "like peer" can be challenging.

PURPOSE

To explore women's reasons for seeking an online exercise partner following a diagnosis with cancer (through  www.activematch.ca ). We also examined women's potential sociodemographic and cancer-related differences by reported reasons for wanting an exercise partner.

METHODS

Individuals creating an ActiveMatch profile completed demographic and physical activity questions (N = 199, Mage(SD) = 51.9(10.8) years), including an open-ended question regarding their "reason for wanting an exercise partner". An inductive content analysis was completed focusing on the participants' peer exercise partner preferences. Additional chi-square tests were run to assess whether participants differed based on sociodemographic and cancer-related characteristics and their motivations to be active by category of "reason for wanting an exercise partner" endorsed in the open-ended question.

RESULTS

The participants' reasons for wanting an exercise partner were coded into seven categories, with most participants highlighting the reasons of motivation (52.3%), social support (48.7%), and accountability and adherence (26.6%). Women < 50 years of age were more likely to report accountability and adherence-related preferences for a partner. Those reporting endorsing weight loss as their primary reason for becoming active were more likely to be categorized as wanting a peer partner for motivation.

CONCLUSIONS

While finding a peer partner can be challenging, matching women living with and beyond a cancer diagnosis based on their reason for wanting an exercise partner, as well as their reasons for wanting to be active, may be important to build successful peer exercise partnerships.

Factors Influencing the Decision of Individuals with Breast Cancer to Join an Exercise Oncology Trial

Exercise has been found to have numerous benefits for individuals with cancer undergoing treatment. The primary objective of this study was to explore factors that influence the decision to join an exercise trial for individuals with a current diagnosis of breast cancer. A theory-informed survey was administered exploring factors (i.e., attitudes, subjective norms, perceived behavioral control) that influenced participants' decision to join the "NEXT-BRCA" exercise trial. Eligible participants included self-reported females over 18 years, diagnosed with stage 1-3 breast cancer undergoing treatment and cleared for exercise by their oncologist. Survey questions were analyzed using descriptive statistics and exploratory analysis was performed to determine if associations existed between personal characteristics (age, physical activity level, co-morbid conditions) and cancer characteristics (treatment received). Seventy-four participants completed the survey. Most participants (85% of respondents) were interested in increasing their level of physical activity. The most common attitudes contributing to participant's decision to participate in the trial included feelings that exercise was beneficial for improving physical (91%) and mental health (89%). Advice from the treating oncologist was ranked as the most important factor influencing their decision to join the trial (73%). Respondents hoped to gain exercise knowledge through educational materials (72%) and a structured exercise program (70%). Findings explore why individuals with breast cancer participate in exercise trials during treatment. This knowledge will enhance recruitment of future studies using similar interventions and assist clinicians to maximize education regarding exercise and access to exercise programs for individuals with breast cancer in the future.

Attitudes and perceptions of cancer patients and healthcare providers towards prehabilitation: A thematic synthesis

PURPOSE

Prehabilitation, which is the process of enhancing functional capacity before undergoing surgery or other treatments, has been shown to improve cancer patients' outcomes. Patient and healthcare provider attitudes and perceptions are essential factors in the successful implementation of prehabilitation. The purpose of this systematic review is to synthesize qualitative evidence and explore the barriers and facilitators to prehabilitation implementation.

METHODS

From the earliest available date to October 2023, 7 databases (PubMed, Web of Science, Cochrane Library, Embase, CINAHL, PsycINFO, and MEDLINE) were searched for a systematic review. Data were extracted, thematically analysed, and mapped onto the Capability, Opportunity, and Motivation Model of Behaviour (COM-B). The Critical Appraisal Skills Programme (CASP) tool was used to assess the quality of the studies.

RESULTS

A total of 26 studies were included, involving 377 patients, 51 caregivers, and 156 healthcare providers. 16 factors were identified and mapped onto the COM-B model: reflective/automatic motivation, physical/social opportunity, physical/ psychological capability.

CONCLUSIONS

Patients and healthcare provides identified a lack of reflective motivation and physical opportunities as the most significant barriers to engagement in prehabilitation. Personalized approaches, social support, and healthcare providers' engagement are key factors for prehabilitation. Future research should focus on developing effective interventions to enhance the uptake and sustainability of prehabilitation.

Personalised exercise rehabilitation in cancer survivorship: the percs triage and referral system study protocol

BACKGROUND

To effectively embed exercise rehabilitation in cancer survivorship care, a co-ordinated system of acute and community exercise rehabilitation services, forming a stepped model of care, is recommended. Patients can be directed to the exercise rehabilitation service which best meets their needs through a system of assessment, triage and referral. Triage and referral systems are not yet widely applied in cancer survivorship practice and need to be evaluated in real-world contexts. The PERCS (Personalised Exercise Rehabilitation in Cancer Survivorship) study aims to evaluate the real-world application of an exercise rehabilitation triage and referral system in cancer survivors treated during the COVID-19 pandemic. Secondary aims are to evaluate change in physical and psychosocial outcomes, and to qualitatively evaluate the impact of the system and patient experiences, at three months after application of the triage and referral system.

METHODS

This study will assess the implementation of an exercise rehabilitation triage and referral system within the context of a physiotherapy-led cancer rehabilitation clinic for cancer survivors who received cancer treatment during the COVID-19 pandemic. The PERCS triage and referral system supports decision making in exercise rehabilitation referral by recommending one of three pathways: independent exercise; fitness professional referral; or health professional referral. Up to 100 adult cancer survivors treated during the COVID-19 pandemic who have completed treatment and have no signs of active disease will be recruited. We will assess participants' physical and psychosocial wellbeing and evaluate whether medical clearance for exercise is needed. Participants will then be triaged to a referral pathway and an exercise recommendation will be collaboratively decided. Reassessment will be after 12 weeks. Primary outcomes are implementation-related, guided by the RE-AIM framework. Secondary outcomes include physical function, psychosocial wellbeing and exercise levels. Qualitative analysis of semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) will provide insights on implementation and system impact.

DISCUSSION

The PERCS study will investigate the real-world application of a cancer rehabilitation triage and referral system. This will provide proof of concept evidence for this triage approach and important insights on the implementation of a triage system in a specialist cancer centre.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov, registration number: NCT05615285, date registered: 21st October 2022.

CaRE@ELLICSR: Effects of a clinically integrated, group-based, multidimensional cancer rehabilitation program

BACKGROUND

Although oncology clinical practice guidelines recognize the need and benefits of exercise, the implementation of these services into cancer care delivery remains limited. We developed and evaluated the impact of a clinically integrated 8-week exercise and education program (CaRE@ELLICSR).

METHODS

We conducted a mixed methods, prospective cohort study to examine the effects of the program. Each week, participants attended a 1-h exercise class, followed by a 1.5-h education session. Questionnaires, 6-min walk tests (6MWT), and grip strength were completed at baseline (T0), 8 weeks (T1), and 20 weeks (T2). Semi-structured interviews were conducted with a sub-sample of participants about their experience with the program.

RESULTS

Between September 2017 and February 2020, 277 patients enrolled in the program and 210 consented to participate in the research study. The mean age of participants was 55 years. Participants were mostly female (78%), white/Caucasian (55%) and half had breast cancer (50%). Participants experienced statistical and clinically meaninful improvements from T0 to T1 in disability, 6MWT, grip strength, physical activity, and several cancer-related symptoms. These outcomes were maintained 3 months after program completion (T2). Qualitative interviews supported these findings and three themes emerged from the interviews: (1) empowerment and control, (2) supervision and internal program support, and (3) external program support.

CONCLUSIONS

This study demonstrates the impact of overcoming common organizational barriers to deliver exercise and rehabilitation as part of routine care. CaRE@ELLICSR demonstrated clinically meaningful improvements in patient-reported and functional outcomes and was considered beneficial and important by participants for their recovery and wellbeing.

Perceived autonomy support from healthcare professionals and physical activity among breast cancer survivors: A propensity score analysis

The majority of women treated for breast cancer are physically inactive although physical activity (PA) could attenuate many adverse effects of cancer and treatment. Autonomy support from healthcare professionals may improve PA initiation, adherence and maintenance. This study aimed to determine, using a causal inference approach, whether or not perceived autonomy support (PAS) from healthcare professionals is associated with light, moderate, and vigorous intensity PA among women treated for breast cancer. Data were drawn from the longitudinal study "Life After Breast Cancer: Moving On" (n = 199). PAS was measured with the Health Care Climate Questionnaire and PA was assessed using GT3X triaxial accelerometers. Associations between PAS and PA were estimated with linear regressions and adjusted estimations were obtained using propensity score-based inverse probability of treatment weights (IPTW). Results reveal no association between PAS and PA of light ([Formula: see text](95%CI) = -0.09 (-0.68, 0.49)), moderate ([Formula: see text] (95%CI) = -0.03 (-0.17, 0.11)), or vigorous ([Formula: see text](95%CI) = 0.00 (-0.03, 0.02)) intensity. Different forms of engagement and support by healthcare professionals should be explored to identify the best intervention targets to encourage women to adopt and maintain regular PA in the cancer continuum.

Healthcare providers' promotion of physical activity among child and adolescent cancer survivors: strategies and challenges

PURPOSE

This study aims to investigate how healthcare providers (HCPs) promote physical activity (PA) to child and adolescent cancer survivors.

METHODS

Semi-structured interviews were conducted with HCPs (n = 16; women n = 12; men n = 4) who provide care for cancer survivor youth (age 3 to 18). Participants represented 7 professions, including child life specialists, oncologists, nurse practitioners, physical therapists, and social workers. A reflexive thematic analysis was conducted to explore the techniques that HCPs use to promote PA for this patient population and ways PA promotion can improve.

RESULTS

HCPs use five strategies to promote PA to cancer survivor youth: (1) broadening the definition of PA, (2) tailoring PA recommendations, (3) including families, (4) connecting patients to programming, and (5) promoting patient motivation.

CONCLUSIONS

This research highlights techniques that HCPs use to promote PA to young cancer survivors and reveals the need for additional ways to support HCPs to improve PA promotion for child and adolescent cancer survivors. While HCPs emphasized the importance of PA for this patient population, they navigate barriers that limit the quality of PA discussions.

IMPLICATIONS FOR CANCER SURVIVORS

Further research should explore interventions to improve PA promotion and PA participation among child and adolescent cancer survivors. By understanding the perspectives of HCPs, patients, and their families, PA promotion strategies can be improved, and more programs that support both patients and practitioners may be developed.

Determinants of physical activity during cancer treatment: a longitudinal exploration of psycho-cognitive variables and physician counseling

Individuals with cancer are recommended to engage in regular physical activity (PA) even during cancer therapy. The aim of this study was to explore how patient-reported physician PA counseling influences their PA intention and behavior in addition to psycho-cognitive determinants derived from the theory of planned behavior (TPB). A longitudinal study during cancer treatment was conducted among N = 115 patients with breast, prostate, or colorectal cancer (Mage = 58.0, SD = 11.5; 55.7% female). The median time since diagnosis was 2 months, and 19.1% were diagnosed with metastases. Participants provided information on PA counseling by their physicians and on psycho-cognitive variables of the TPB at three measurement points. Additionally, they wore accelerometers for seven days at baseline and three months later. Nearly half of participants (48%) reported basic PA counseling and 30% reported in-depth PA counseling. Patients in poorer health and with lower education reported significantly less in-depth counseling. In addition to patient self-efficacy in performing PA, only in-depth physician PA counseling, but not basic physician counseling, predicted intention for PA four weeks later. Patients' PA three months after baseline was predicted by patients' PA at baseline and their intention for PA. Overall, the PA level at baseline was identified as the most important predictor of PA three months later. Nevertheless, physicians seem to have the ability to increase their cancer patients' intention for PA by in-depth counseling.

Milestones and turning points in the experience of physical activity throughout cancer care: a qualitative study to inform physical activity promotion

PURPOSE

Physical activity (PA) is an important supportive care strategy to manage cancer and treatment-related side effects, yet PA participation is low among people diagnosed with cancer. This study examined patients', health professionals', and managers' perspectives on PA throughout cancer care to glean implications for PA promotion.

METHODS

Random selection and purposeful sampling methods allowed for the recruitment of 21 patients (76.2% women) and 20 health professionals and managers (80% women) who participated in individual semi-structured interviews. Interview questions explored facilitators and barriers to PA participation and promotion across the cancer care continuum. Interviews were audio-recorded and transcribed. Then, qualitative thematic analysis was performed.

RESULTS

The analysis produced five main themes describing milestones in PA participation throughout cancer care: (1) Getting Started, (2) Discovering PA Resources, (3) Taking Action, (4) Striving for Change, and (5) Returning to a "New Normal." The sub-themes underscored turning points, i.e., tasks and challenges to PA participation that had to be overcome at each milestone. Achieving milestones and successfully navigating turning points were dependent on clinical, social, and community factors.

CONCLUSION

Cancer patients appear to progress through a series of milestones in adopting and maintaining PA throughout cancer care. Intervention strategies aimed at promoting PA could test whether support in navigating turning points could lead to greater PA participation. These findings require replication and extension, specifically among patients who are men, younger adults, and culturally diverse.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Capitalization of experience of physical activity resumption programs: Lessons learned for adherence and post-program referral

The benefits of physical activity (PA) in managing chronic diseases are largely demonstrated. To encourage a sustainable PA practice for inactive patients with chronic diseases, France has recently implemented PA resumption programs, in which patients can participate with a medical prescription but which are time-limited. In the literature, the effectiveness of those exercise referral schemes to foster sustainable PA practice is still mixed. The present study aims at capitalizing the experience of eight resumption programs to understand what makes the programs work, adherence mechanisms and the post-program referral scheme. Questionnaires and semi-structured interviews informed those intervention mechanisms analysed using thematic analysis. This study provides insights into expertize in patient management among these programs, currently due to key findings as the employment of adapted PA teachers, their training and the use of mechanisms for program adherence (practice conditions, emphasize progress and feelings generated by exercise, the relational and social aspect of practice). Other key findings are a lack of clarity in program objectives which is an area of improvement, and a broad diversity of referral (transmitting contact details, contacting the club, intervention of a third-party association or physical presence) that need further exploration.

Enhanced recovery after surgery, current, and future considerations in head and neck cancer

Objectives

Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients.

Methods

Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion.

Results

A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation.

Conclusion

Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol.

Level of Evidence

2a.

Exploring the practicality and acceptability a brief exercise communication and clinician referral pathway in cancer care: a feasibility study

BACKGROUND

The majority of cancer patients and cancer care clinicians-CCCs (e.g., oncologists) believe that exercise is an important adjunct therapy that should be embedded in standard practice. Yet, CCCs do not routinely discuss exercise with their patients, nor do they regularly refer them to exercise professionals (e.g., exercise physiologists-EPs). This study evaluated the feasibility and acceptability of an evidence-based approach to improving exercise communication between CCCs and their patients, including an exercise referral pathway.

METHODS

Implementation and testing of the Exercise Communication and Referral Pathway (ECRP) occurred in Sydney, Australia. The ECRP included a brief oncology-initiated communication exchange with patients, CCC exercise referral to an EP, followed by EP-initiated telephone consultation with patients concerning tailored exercise advice. Participant perceptions concerning the feasibility and applicability of the ECPR were evaluated. Semi-structured interviews were conducted with CCCs (n = 3), cancer patients (n = 21), and an EP (n = 1). Inductive thematic analysis was undertaken.

RESULTS

Analysis generated three themes: (1) Navigating the role of CCCs in the ECRP, suggesting that oncology-initiated communication is a cue to action, however there was a lack of role clarity regarding exercise referral; (2) Implementing Patient-Orientated Care within a Standardised Pathway, highlighting the need for tailored information and advice for patients that reflects individual disease, socio-cultural, and environmental factors, and; (3) Taking Steps Towards Action, revealing the need for structural (e.g., EP initiated contact with patients) and policy changes (i.e., changes to Medicare, direct oncologist referral) to engage patients and better integrate exercise as part of standard care.

CONCLUSIONS

Findings provide important insights into improving oncology-patient exercise communication and developing an exercise referral pathway to increase engagement and patient reach. However, individual (e.g., experience, knowledge) and contextual factors (e.g., time, resources) need consideration when implementing an ECRP.

TRIAL REGISTRATION

This trial was prospectively registered with the Australian New Zealand Clinical (#ACTRN12620000358943) on March 13, 2020.

Information needs of women with breast cancer participating in cardiovascular rehabilitation: A mixed-methods study

OBJECTIVE

To determine the information needs of women with a history of breast cancer attending a cardiovascular rehabilitation (CR) program.

METHODS

A mixed-methods approach was used, including a cross-sectional online survey using an adapted version of the Toronto Information Needs Questionnaire Breast Cancer (TINQ-BC) and 7 virtual focus group sessions (n = 20).

RESULTS

Overall, 50 responses were received. The TINQ-BC mean was 4.2 ± 0.5/5, with 34/42 items scoring higher than 4 (very important). The highest information needs were related to knowing if cancer is in their bodies or has come back, ways to prevent treatment side effects, and how the illness may affect their future. Participants identified their preferences for education delivery as discussion with peers/healthcare providers and lectures. The focus groups revealed six overarching themes: need for peer support, to make connections, and build relationships; comfort with and utility of technology; desire to learn about specific educational topics; preferences for education sessions; value of education; and value of exercise.

CONCLUSIONS

These findings provided insight into the information needs of women with a history of breast cancer who participate in CR.

PRACTICAL IMPLICATION

The care of these patients should be personalized based on these needs to support their adherence to the program.

Promoting physical activity through supervised vs motivational behavior change interventions in breast cancer survivors on aromatase inhibitors (PAC-WOMAN): protocol for a 3-arm pragmatic randomized controlled trial

BACKGROUND

Aromatase inhibitors (AI) are frequently used to treat hormone-receptor-positive breast cancer, but they have multiple adverse effects (e.g., osteoporosis, arthralgia), resulting in premature therapy discontinuation/switch. Physical activity (PA) can attenuate these negative effects and improve quality of life (QoL). However, most cancer survivors fail to perform/sustain adequate PA levels, especially in the long-term. Theory-based interventions, using evidence-based behavior change techniques, aimed at promoting long-term behavior change in breast cancer survivors are effective, but remain scarce and fail to promote self-regulatory skills and better-quality motivations associated with sustained PA adoption. This paper describes the design of the PAC-WOMAN trial, which will test the long-term effectiveness and cost-effectiveness of two state of the art, group-based interventions encouraging sustained changes in PA, sedentary behavior, and QoL. Additional aims include examining the impact of both interventions on secondary outcomes (e.g., body composition, physical function), and key moderators/mediators of short and long-term changes in primary outcomes.

METHODS

A 3-arm pragmatic randomized controlled trial, involving a 4-month intervention and a 12-month follow-up, will be implemented, in a real exercise setting, to compare: 1) brief PA counseling/motivational intervention; 2) structured exercise program vs. waiting-list control group. Study recruitment goal is 122 hormone-receptor-positive breast cancer survivors (stage I-III), on AI therapy (post-primary treatment completion) ≥ 1 month, ECOG 0-1. Outcome measures will be obtained at baseline, 4 months (i.e., post-intervention), 10 and 16 months. Process evaluation, analyzing implementation determinants, will also be conducted.

DISCUSSION

PAC-WOMAN is expected to have a relevant impact on participants PA and QoL and provide insights for the improvement of interventions designed to promote sustained adherence to active lifestyle behaviors, facilitating its translation to community settings.

TRIAL REGISTRATION

April 20, 2023 - NCT05860621. April 21, 2023 - https://doi.org/10.17605/OSF.IO/ZAQ9N April 27, 2023 - UMIN000050945.

Feasibility and Implementation of an Oncology Rehabilitation Triage Clinic: Assessing Rehabilitation, Exercise Need, and Triage Pathways within the Alberta Cancer Exercise-Neuro-Oncology Study

Individuals living with and beyond cancer face physical impairment and inactivity in survivorship. Neuro-oncology populations have especially high rates of sedentary behaviour and functional deficits, including impaired balance, motor skills, and cognition. Our purpose was to assess the rehabilitation and exercise needs of patients with brain tumours while examining the feasibility of a rehabilitation triage clinic as a part of the Alberta Cancer Exercise-Neuro-Oncology study, where patients were referred to a triage clinic, where health, neurologic, and functional status was assessed, followed by a referral to one or multiple resources, including exercise, physiotherapy, occupational therapy, or physiatry. Qualitative perception of the triage clinic was collected. Overall, the triage clinic was feasible and safe for participants, facilitating referral into rehabilitation and exercise resources. Pre-determined enrollment and attendance rates were met, but referral rates to the triage clinic were not met. Oncology clinic staff reported forgetting to refer patients or uncertainty of who was appropriate for rehabilitation as barriers. Oncology clinic-based screening may improve the identification of patients who are sedentary or have a physical impairment. A proposed screening tool, the Cancer Rehabilitation and Exercise Screening Tool (CREST), is presented within our Cancer Rehabilitation and Exercise Pathways Model. The CREST can identify patients who are sedentary or have a functional impairment, facilitating referral to appropriate rehabilitation resources and ultimately improving patient recovery and functioning.

Preferences and engagement with physical activity resources among cancer survivors during the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic has imposed additional barriers to physical activity (PA) in cancer survivors. Adaptations to PA programmes are needed during the pandemic. Therefore, the purpose of this study was to evaluate (1) the PA preferences of cancer survivors prior to and during the pandemic and (2) the available resources to engage in PA during the pandemic.

METHODS

Using a cross-sectional study design, cancer survivors were recruited globally to participate in a self-administered survey assessing their PA preferences and available PA resources during the pandemic. Descriptive statistics were used to determine trends in PA preferences and resources. A sub-group analysis was conducted for age, gender, education, and PA levels.

RESULTS

Cancer survivors (N = 493) were mainly women (70.4%) diagnosed with breast cancer (29.0%), with a mean age of 48.7 ± 15.8 years, and 87.1 ± 81.9 months since diagnosis. Since the start of the pandemic, cancer survivors were primarily walking (82.6%), and performing PA alone (62.7%) and at home (46.6%). Sub-group analysis revealed education level, PA levels, and age to be associated with significant differences in PA preferences. The most common equipment available to survivors in their homes were exercise mats (40.6%) and free weights (39.8%). Few survivors were made aware of at-home PA resources (19.1%), and approximately half indicated wanting to receive these resources (49.6%).

CONCLUSIONS

Understanding cancer survivors' preferences and resources for PA during the pandemic is critical to designing effective home-based interventions. Interventions and recommendations should be tailored based on the level of education and PA participation, as well as age.

Design and methods of a translational, community-based, lifestyle weight management pilot intervention trial in breast cancer survivors with overweight or obesity

Background

Breast cancer survivors (BCS) with overweight or obesity are at heightened risk of cancer recurrence, cardiometabolic disease, and compromised quality of life. Given the prevalence of significant weight gain during and following breast cancer treatment, there is growing recognition of the need to develop efficacious, widely-accessible, weight management programs for BCS. Unfortunately, access to evidence-based weight management resources for BCS remains limited and little is known of the optimal theoretical basis, program components, and mode of delivery for community-based interventions. The primary aim of the Healthy New Albany Breast Cancer (HNABC) pilot trial was to determine the safety, feasibility, and preliminary efficacy of delivering a translational, evidence-based, and theory-driven lifestyle weight management intervention to BCS with overweight or obesity in the community setting.

Methods

HNABC was a single-arm, pilot trial evaluating a 24-week, multi-component intervention leveraging exercise, dietary modification, and group-mediated cognitive behavioral (GMCB) counseling components designed to facilitate lifestyle behavior change and promote sustained independent adherence. Assessments of various objectively-determined and patient-reported outcomes and theory-derived determinants of behavioral adoption and maintenance were obtained at baseline, 3- and 6-month follow-up. Measures of trial feasibility were calculated prospectively throughout the study.

Conclusion

Findings from the HNABC pilot trial will provide evidence demonstrating the feasibility and preliminary efficacy of a multi-component, community-based, GMCB lifestyle weight management intervention for BCS. Results will inform the design of a future, large-scale, randomized controlled efficacy trial. If successful, this approach could offer a widely accessible, community-based intervention model for weight management programs in BCS.

Harms of exercise training in patients with cancer undergoing systemic treatment: a systematic review and meta-analysis of published and unpublished controlled trials

Background

Exercise is recommended for people with cancer. The aim of this study was to evaluate the harms of exercise in patients with cancer undergoing systemic treatment.

Methods

This systematic review and meta-analysis included published and unpublished controlled trials comparing exercise interventions versus controls in adults with cancer scheduled to undergo systemic treatment. The primary outcomes were adverse events, health-care utilization, and treatment tolerability and response. Eleven electronic databases and trial registries were systematically searched with no date or language restrictions. The latest searches were performed on April 26, 2022. The risk of bias was judged using RoB2 and ROBINS-I, and the certainty of evidence for primary outcomes was assessed using GRADE. Data were statistically synthesised using pre-specified random-effect meta-analyses. The protocol for this study was registered in the PROESPERO database (ID: CRD42021266882).

Findings

129 controlled trials including 12,044 participants were eligible. Primary meta-analyses revealed evidence of a higher risk of some harms, including serious adverse events (risk ratio [95% CI]: 1.87 [1.47-2.39], I2 = 0%, n = 1722, k = 10), thromboses (risk ratio [95% CI]: 1.67 [1.11-2.51], I2 = 0%, n = 934, k = 6), and fractures (risk ratio [95% CI]: 3.07 [3.03-3.11], I2 = 0%, n = 203, k = 2) in intervention versus control. In contrast, we found evidence of a lower risk of fever (risk ratio [95% CI]: 0.69 [0.55-0.87], I2 = 0% n = 1109, k = 7) and a higher relative dose intensity of systemic treatment (difference in means [95% CI]: 1.50% [0.14-2.85], I2 = 0% n = 1110, k = 13) in intervention versus control. For all outcomes, we downgraded the certainty of evidence due to imprecision, risk of bias, and indirectness, resulting in very low certainty of evidence.

Interpretation

The harms of exercise in patients with cancer undergoing systemic treatment are uncertain, and there is currently insufficient data on harms to make evidence-based risk-benefits assessments of the application of structured exercise in this population.

Funding

There was no funding for this study.

The role of exercise for pain management in adults living with and beyond cancer: a systematic review and meta-analysis

BACKGROUND

Pain is a common side effect of cancer or cancer treatment that negatively impacts biopsychosocial wellbeing and quality of life. Exercise is a potential intervention to manage pain that is safe and has multiple benefits. The objective was to determine the role of exercise in cancer pain management.

METHODS

We completed a systematic review and meta-analysis of exercise interventions in adults with any type or stage of cancer by searching Ovid MEDLINE®, Embase, APA PsycInfo, the Cochrane Central Register of Controlled Trials, CINAHL, and SPORTDiscus. We included experimental and quasi-experimental designs where pain was measured as an outcome. Data synthesis included narrative and tabular summary. A meta-analysis was performed on studies powered to detect the effect of exercise on pain. Study quality was evaluated using the Cochrane risk of bias tool and certainty of evidence was evaluated using the GRADE tool.

RESULTS

Seventy-six studies were included. Studies were predominantly conducted in breast cancer and exercise usually included a combination of aerobic and strength training. Ten studies were included in the meta-analysis demonstrating a significant effect for exercise in decreasing pain (estimated average standard mean difference (SMD) was g =  - 0.73 (95% CI: - 1.16 to - 0.30)); however, the overall effect prediction interval was large. Overall risk of bias for most studies was rated as some concerns and the grading of evidence certainty was low.

CONCLUSION

There are limitations in the evidence for exercise to manage cancer-related pain. Further research is needed to understand the role of exercise in a multimodal pain management strategy.

Patient Comments on a Hospital- and University-Based Exercise Oncology Program

The purpose of this study was to identify referral source and patient-reported factors that promoted follow-through and participation in exercise oncology rehabilitation programs. A three question open-ended survey was administered to patients enrolled in trainer-supervised, hospital-based (n = 101), or university-based (n = 17) cancer rehabilitation program that provided 12 weeks of individualized one on one aerobic and resistance training 1-3 days per week. Significant themes for each question were as follows: Question #1. Who referred you to the program/facility? Oncology team (Χ² = 145.814 P ≤ 0.001); Question #2. What convinced you to follow through with the referral? Health, fatigue, and need for supervision (Χ² = 74.814 P ≤ 0.001); and Question #3. What motivates you to continue in the program? Personal results, getting healthy, and the trainer (Χ² = 108.729 P ≤ 0.001). In this study, oncology team referral confirms previous work. Patient follow-through and continuation appear largely self-motivated as patients' health and the attainment of health through personal results are primary motivators for continuation in the program. Question #3 responses note the importance of the trainer in maintaining continuation in an exercise oncology rehabilitation program.

Exploring feasibility, perceptions of acceptability, and potential benefits of an 8-week yoga intervention delivered by videoconference for young adults affected by cancer: a single-arm hybrid effectiveness-implementation pilot study

BACKGROUND

Young adults affected by cancer face physical and psychological challenges and desire online supportive care. Yoga can be delivered online and may improve physical and psychological outcomes. Yet, yoga has rarely been studied with young adults affected by cancer. To address this, an 8-week yoga intervention was developed, and a pilot study was deemed necessary to explore feasibility, acceptability, implementation, and potential benefits.

METHODS

A mixed-methods, single-arm hybrid effectiveness-implementation pilot study evaluating the yoga intervention was conducted. Feasibility was assessed by tracking enrollment, retention, attendance, completeness of data, and adverse events. Acceptability was explored through interviews. Implementation metrics included training time, delivery resources, and fidelity. Potential effectiveness was evaluated by exploring changes in physical (i.e., balance, flexibility, range of motion, functional mobility) and psychological (i.e., quality of life, fatigue, resilience, posttraumatic growth, body image, mindfulness, perceived stress) outcomes at pre- (week 0), post- (week 8), and follow-up (week 16) time points. Data were analyzed with descriptive statistics, repeated measures analysis of variance, and content analysis.

RESULTS

Thirty young adults participated in this study (recruitment rate = 33%). Retention to study procedures was 70%, and attendance ranged from 38 to 100%. There were little missing data (< 5%) and no adverse events. Though most participants were satisfied with the yoga intervention, recommendations for improvement were shared. Sixty study-specific training hours and > 240 delivery and assessment hours were accrued and fidelity was high. Functional mobility, flexibility, quality of life (energy/fatigue, social well-being), body image (appearance evaluation), mindfulness (non-reactivity), and perceived stress improved significantly over time (all p< 0.050; [Formula: see text]). No other significant changes were observed (all p> 0.050; [Formula: see text]).

CONCLUSIONS

The yoga intervention may confer physical and psychological benefits, though intervention and study-specific modifications are required to improve feasibility and acceptability. Requiring study participation and providing greater scheduling flexibility could enhance recruitment and retention. Increasing the frequency of classes offered each week and offering more opportunities for participant interaction could improve satisfaction. This study highlights the value of doing pilot work and provides data that has directly informed intervention and study modifications. Findings could also be used by others offering yoga or supportive care by videoconference to young adults affected by cancer.

TRIAL REGISTRATION

Not available-not registered.

Referrals from Healthcare Professionals to Community-Based Exercise Programs Targeting People with Balance and Mobility Limitations: An Interviewer-Administered Survey

Purpose:

To describe program representatives’ perceptions of the: (1) type and work setting of healthcare professionals who refer to community-based exercise programs with healthcare-community partnerships (CBEP-HCPs) by community size; (2) nature, frequency, and utility of strategies used to promote referral from healthcare professionals to CBEP-HCPs; and (3) facilitators and barriers to CBEP-HCP promotion.

Method:

We invited individuals involved with the Together in Movement and Exercise (TIME™) program in 48 centres to participate in a cross-sectional survey. TIME™ is a group, task-oriented CBEP-HCP taught by fitness instructors; healthcare partners promote referrals. Data were summarized using frequencies and percentages. Content analysis was used for open-ended questions.

Results:

Twenty-three representatives of 27 TIME™ programs (56% response rate) participated. Out of 26 healthcare partners identified, 69% were physical therapists. We report the most common findings: programs received referrals from physical therapists ( n = 16, 70%); programs gave healthcare partners promotional materials (e.g., flyers) to facilitate referrals ( n = 17, 63%); strong relationships with healthcare partners facilitated promotion ( n = 18, 78%); and representatives perceived their lack of credibility challenged promotion ( n = 3, 23%).

Conclusions:

Physical therapists were the most common referral source. Healthcare partners were instrumental in program promotion. Future research is needed to leverage referrals from physical therapists in settings other than hospitals and to better understand the role of healthcare partners in CBEP-HCPs.

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

Introduction/Purpose

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

Methods

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

Results

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

Conclusions

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

First-Year Implementation of the EXercise for Cancer to Enhance Living Well (EXCEL) Study: Building Networks to Support Rural and Remote Community Access to Exercise Oncology Resources

Barriers to exercise-oncology programs remain for those living with and beyond cancer in rural and remote communities, including geographic isolation and access to programs. The EXercise for Cancer to Enhance Living Well (EXCEL) study was designed to support exercise-oncology implementation in rural and remote communities across Canada. The purpose of this analysis was to evaluate the first-year reach, adoption, and implementation of the EXCEL study. Reach outcomes included participant characteristics, study enrolment, and referral type (self vs. healthcare-provider [HCP] referral). Adoption outcomes included the number of clinical contacts, trained qualified exercise professionals (QEPs), and QEPs delivering EXCEL exercise classes. Implementation outcomes included retention, adherence, assessment completion rates, and adverse-event reporting. A total of 290 individuals living with cancer enrolled in EXCEL in year one, with an 81.4% retention to the study intervention. Most participants self-referred to EXCEL (75.8%). EXCEL's HCP network consisted of 163 clinical contacts, and the QEP network included 45 trained QEPs, 22 of whom delivered EXCEL classes. Adherence to the exercise intervention was 78.2%, and only one adverse event (mild) was reported. Fitness assessment and patient-reported outcome completion rates were above 85% pre- and post-intervention. EXCEL has developed HCP and QEP networks supporting exercise referral and online delivery, and the intervention is meeting feasibility markers. These implementation findings will inform the continued gathering of feedback across stakeholders to ensure that best evidence informs best practices.

Evaluation of a city-wide physical activity pathway for people affected by cancer: the Active Everyday service

PURPOSE

The primary goal of this article is to present an evaluation of a UK-based city-wide physical activity pathway for patients with a cancer diagnosis, the Active Everyday service. Active Everyday was a co-produced physical activity service for people affected by cancer. The service was underpinned by a behaviour change care pathway model developed by Macmillan Cancer Support charity.

METHODS

This was a retrospective evaluation assessing physical activity levels and changes to outcome measures (fatigue, perceived health, and self-efficacy) over 6 months. Each participant self-reported their levels of physical activity for the previous 7 days at three-time points: baseline (T1), at 12-week exit from the scheme (T2), and at 6-month follow-up (T3).

RESULTS

The Active Everyday service received 395 referrals, of which 252 attended a baseline assessment. Participants' fatigue and self-efficacy improved between T1 and T2 and T1 and T3. Perceived health improved across all time points. Participant exercise levels showed significant differences between T1 and T2.

CONCLUSION

The service, provided over 3 years, resulted in positive health and wellbeing outcomes in people affected by cancer who engaged in the service. Future services must routinely include exercise referrals/prescriptions as a standard part of care to help engage inactive individuals. Services should focus on targeted promotion to people from ethnic minority groups, and a wide socioeconomic population.

Implementing an exercise oncology model to reach rural and remote individuals living with and beyond cancer: a hybrid effectiveness-implementation protocol for project EXCEL (EXercise for Cancer to Enhance Living Well)

INTRODUCTION

Individuals living with and beyond cancer from rural and remote areas lack accessibility to supportive cancer care resources compared with those in urban areas. Exercise is an evidence-based intervention that is a safe and effective supportive cancer care resource, improving physical fitness and function, well-being and quality of life. Thus, it is imperative that exercise oncology programs are accessible for all individuals living with cancer, regardless of geographical location. To improve accessibility to exercise oncology programs, we have designed the EXercise for Cancer to Enhance Living Well (EXCEL) study.

METHODS AND ANALYSIS

EXCEL is a hybrid effectiveness-implementation study. Exercise-based oncology knowledge from clinical exercise physiologists supports healthcare professionals and community-based qualified exercise professionals, facilitating exercise oncology education, referrals and programming. Recruitment began in September 2020 and will continue for 5 years with the goal to enroll ~1500 individuals from rural and remote areas. All tumour groups are eligible, and participants must be 18 years or older. Participants take part in a 12-week multimodal progressive exercise intervention currently being delivered online. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework is used to determine the impact of EXCEL at participant and institutional levels. Physical activity, functional fitness and patient-reported outcomes are assessed at baseline and 12-week time points of the EXCEL exercise intervention.

ETHICS AND DISSEMINATION

The study was approved by the Health Research Ethics Board of Alberta. Our team will disseminate EXCEL information through quarterly newsletters to stakeholders, including participants, qualified exercise professionals, healthcare professionals and community networks. Ongoing outreach includes community presentations (eg, support groups, fitness companies) that provide study updates and exercise resources. Our team will publish manuscripts and present at conferences on EXCEL's ongoing implementation efforts across the 5-year study.

TRIAL REGISTRATION NUMBER

NCT04478851.

A Survey-Based Study on Physical Activity Promotion for Individuals with a Current or Past Diagnosis of Cancer in Canada

PURPOSE

To determine the prevalence and content of discussions regarding physical activity (PA) promotion between individuals with a current or past diagnosis of cancer and their oncology care team.

METHODS

Design and Procedure: A cross-sectional survey on PA discussion between individuals with a current or past diagnosis of cancer and their oncology care team was conducted at a single timepoint.

PARTICIPANTS

Eligible participants were adults with a current or past diagnosis of cancer at any time point in their cancer treatment who had a pre-scheduled appointment with their oncology care team.

RESULTS

A total of 100 participants completed the survey. PA-related discussions happened in 41% of the patient-provider interactions and 66% of respondents reported PA discussions at some point during care. No significant association occurred between cancer type, stage, or treatment status and PA discussions at any timepoint (all p's > 0.05). Most respondents were satisfied with the education provided on PA (54%); however, only 37% were sufficiently active. Those receiving education from their medical oncologist were more likely to be 'sufficiently active' (p = 0.020) according to the Godin Leisure Time Exercise Questionnaire.

CONCLUSIONS

Most respondents discuss PA with an oncology care provider at some point during their cancer treatment; however, few are sufficiently active. Future research is needed to determine strategies to facilitate PA promotion and close the gap between discussions and actual physical activity behavior.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Innovation

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

Virtual or In-Person: A Mixed Methods Survey to Determine Exercise Programming Preferences during COVID-19

A survey was conducted to identify barriers and facilitators to engaging in virtual and in-person cancer-specific exercise during COVID-19. A theory-informed, multi-method, cross-sectional survey was electronically distributed to 192 individuals with cancer investigating preferences towards exercise programming during COVID-19. Respondents had previously participated in an exercise program and comprised two groups: those who had experience with virtual exercise programming ('Virtual') and those who had only taken part in in-person exercise ('In-Person'). Quantitative data were summarized descriptively. Qualitative data were thematically categorized using framework analysis and findings were mapped to an implementation model. The survey completion response rate was 66% (N = 127). All respondents identified barriers to attending in-person exercise programming during COVID-19 with concerns over the increased risk of viral exposure. Virtual respondents (n = 39) reported: (1) feeling confident in engaging in virtual exercise; and (2) enhanced motivation, accessibility and effectiveness as facilitators to virtual exercise. In-Person respondents (n = 88) identified: (1) technology as a barrier to virtual exercise; and (2) low motivation, accessibility and exercise effectiveness as barriers towards virtual exercise. Sixty-six percent (n = 58) of In-Person respondents reported that technology support would increase their willingness to exercise virtually. With appropriately targeted support, perceived barriers to accessing virtual exercise-including motivation, accessibility and effectiveness-may become facilitators. The availability of technology support may increase the engagement of individuals with cancer towards virtual exercise programming.

Implementation of a Standard Care Program of Therapeutic Exercise in Metastatic Breast Cancer Patients

BACKGROUND

There is little information on the feasibility and benefit of therapeutic exercise (TE) in women with metastatic breast cancer (MBC). The aim of this article is to describe the implementation of a TE intervention in MBC patients, and to determine the recruitment, compliance and improvement in outcomes after its completion.

METHODS

The "Therapeutic Exercise program in MBC" (TEP-MBC) consists of 1 h of individualized TE supervised by a physiotherapist in a group format, consisting of four groups of seven to eight participants. TEP-MBC was delivered twice a week, lasting 12 weeks (22 sessions), with patients considered to have completed the program when attending at least 17 sessions (>75% attendance). After referral, patients underwent a clinical interview and a physical and functional assessment. This information was complemented with patient-reported outcomes. Data about referral, compliance and assessment were collected.

RESULTS

Only 11 of the 30 patients completed the program. Drop-out was mainly related to personal issues and symptoms arising from the disease or treatment. All patients who completed the program improved cancer-related fatigue and increased their functional parameters.

CONCLUSIONS

The TEP-MBC was safe and feasible in patients with MBC, although with low compliance. The high variability in baseline measures reflects the heterogeneous level of function.

A Qualitative Study of Patient and Healthcare Provider Perspectives on Building Multiphasic Exercise Prehabilitation into the Surgical Care Pathway for Head and Neck Cancer

Head and neck cancer (HNC) surgical patients experience a high symptom burden. Multiphasic exercise prehabilitation has the potential to improve patient outcomes, and to implement it into the care pathway, the perspectives of patients and healthcare providers (HCPs) must be considered. The purpose of this study was thus to gather feedback from HNC surgical patients and HCPs on building exercise into the standard HNC surgical care pathway. Methods: Semi-structured interviews were conducted with patients and HCPs as part of a feasibility study assessing patient-reported outcomes, physical function, and in-hospital mobilization. Interview questions included satisfaction with study recruitment, assessment completion, impact on clinical workflow (HCPs), and perceptions of a future multiphasic exercise prehabilitation program. This study followed an interpretive description methodology. Results: Ten patients and ten HCPs participated in this study. Four themes were identified: (1) acceptability and necessity of assessments, (2) the value of exercise, (3) the components of an ideal exercise program, and (4) factors to support implementation. Conclusion: These findings highlight the value of exercise across the HNC surgical timeline from both the patient and the HCP perspective. Results have informed the implementation of a multiphasic exercise prehabilitation trial in HNC surgical patients.

Developing practice guidelines to integrate physical activity promotion as part of routine cancer care: A knowledge-to-action protocol

Background

Cancer is a leading cause of disease burden worldwide and the first cause of mortality in Canada with 30.2% of deaths attributable to cancer. Given aging of the population and the improvement of prevention and treatment protocols, the number of cancer survivors is steadily increasing. These individuals have unique physical and mental health needs some of which can be addressed by integrating physical activity promotion into ongoing and long-term care. Despite the benefits of being active, delivery of PA programs for cancer patients in both clinical and community settings remains challenging. This knowledge-to-action protocol–called Kiné-Onco–aims to develop a practice guideline for the delivery, implementation, and scaling-up of cancer-specific physical activity promotion programs and services in clinical and community settings located in Québec, Canada.

Method

The Kiné-Onco project involves knowledge synthesis of scientific and grey literature to establish the benefits and added value of physical activity for cancer patients and survivors, describes current practices in delivering physical activity programs, analyses quantitative data from electronic health records (EHR) of patients participating in a novel hospital-based physical activity program, collects and analyses qualitative data from patients and healthcare providers interviews about lived experience, facilitators, and barriers to physical activity promotion, outlines deliberative workshops among multidisciplinary team members to develop implementation guidelines for physical activity promotion, and summarizes a variety of knowledge transfer and exchange activities to disseminate the practice guidelines.

Discussion

This paper describes the protocol for a knowledge-to-action project aimed at producing and sharing actionable evidence. Our aim is that physical activity promotion programs and services be scaled up in such a way as to successfully integrate physical activity promotion throughout cancer treatment and survivorship in order to improve the physical and mental health of the growing population of individuals having received a cancer diagnosis.

Tailoring the Evidence for Exercise Oncology within Breast Cancer Care

Exercise is safe and effective for those living with and beyond breast cancer, with evidence supporting exercise guidelines, and position statements from international organizations. Despite the clearly recognized benefits of exercise for these individuals, many do not participate or maintain recommended exercise levels throughout the breast cancer continuum, highlighting the lack of translation from research into practice. In addition, discerning how exercise can be tailored to address breast cancer-related impairments, so that individuals are able to participate safely and effectively, has also not been studied extensively. Thus, we propose that implementing exercise screening, triage, and referral pathways across the breast cancer continuum may allow for increased accessibility and adoption among those living with and beyond breast cancer. This paper provides an overview of exercise prescription tailoring for common breast cancer and treatment-related impairments, proposes a simplified screening tool for identifying physical activity and movement-related impairments, and considers how best to channel evidence into practice via proposed implementation pathways that may better connect individuals living with and beyond breast cancer with exercise oncology resources through screening, triage, and referral.

Bridging the gap between attitudes and action: A qualitative exploration of clinician and exercise professional's perceptions to increase opportunities for exercise counselling and referral in cancer care

OBJECTIVE

This study aimed to 1) understand factors impacting the implementation of exercise communication and referral, and 2) explore integrated clinical approaches to exercise communication and referral in cancer care.

METHODS

Seven focus groups (N = 53) were conducted with clinicians and exercise professionals throughout Sydney, Australia. A sub-sample of participants (n = 9) attended a half-day workshop to identifying best practice approaches for moving forward. Data were analysed using thematic content analysis.

RESULTS

Two themes emerged: 1) Factors impacting the knowledge-to-action gap, inclusive of limited exercise specific knowledge and training opportunities, funding structure, and current referral process, and 2) Recommendations for a consistent and efficient way forward, detailing the need for oncologist-initiated communication, distribution of cancer-exercise resources, and access to exercise professionals with cancer expertise.

CONCLUSIONS

This study identified factors (e.g., cancer-exercise specific training, integration of exercise physiologists) influencing exercise counselling and referral. A potential implementation-referral approach accounting for these factors and how to incorporate exercise into a standard model of cancer care, is described. Future testing is required to determine feasibility and practicality of these approaches.

PRACTICAL IMPLICATIONS

A pragmatic model is provided to guide implementation-referral, inclusive of oncologist-initiated communication exchange, relevant resources, and access to exercise professionals with cancer expertise.

Feasibility of Implementing Cancer-Specific Community-Based Exercise Programming: A Multi-Centre Randomized Trial

BACKGROUND

There is growing recognition of the importance of reporting preliminary work on the feasibility of a trial. The present study aimed to assess the feasibility of (1) a proposed fitness testing battery, and (2) processes related to the implementation of cancer-specific exercise programming in a community setting.

METHODS/DESIGN

A randomized controlled implementation feasibility trial was performed in advance of a large-scale implementation study. Eligible participants within 18 months of a cancer diagnosis were randomized to immediate or delayed community-based exercise at YMCA locations in Calgary and Edmonton, Canada for an 8-week period. The primary outcome for the trial was the feasibility of the physical fitness testing battery, defined as a 70% or greater completion rate across the 24-week study period. The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework was used to evaluate processes related to implementation of the exercise program across the two sites.

RESULTS

Eighty participants were recruited, 73 (91%) completed the 8-week trial, and 68 (85%) completed the 16- and 24-week follow-ups. Sixty participants (75%) completed the full physical fitness test battery at each time point, and 59 (74%) completed the patient-reported outcome measures. Statistically significant between-group differences were found in favor of the exercise group for functional aerobic capacity, upper and lower extremity strength, and symptoms. Differences were found between the sites, however, in completion rates and processes related to program implementation.

DISCUSSION

Findings suggest the need for minor adaptations to the physical fitness battery and outcome measures to better fit the community context. While findings support feasibility, context-specific challenges related to implementation processes were identified.

ACE-Neuro: A tailored exercise oncology program for neuro-oncology patients – Study protocol

Background

Methods

Conclusion

•

Neuro-oncology patients require access to tailored exercise oncology programs.

•

The feasibility of a tailored neuro-oncology exercise program is being examined.

•

Patients are referred and triaged via the electronic medical record.

•

Intervention includes tailored exercise, an activity tracker, and health coaching.

•

This work supports the implementation of exercise within neuro-oncology care.

"Your Body Is Not At All Where You Left It": Adolescent and Young Adult Cancer Survivors' Experiences Transitioning Back Into Physical Activity After Treatment

Physical activity (PA) can help manage cancer treatment-related side effects and improve well-being following treatment; however, resuming PA after a period of inactivity due to cancer can be challenging. The purpose of this study was to explore adolescents and young adults (AYAs) experiences transitioning back into PA after a period of inactivity due to cancer treatment. Twelve previously active AYAs (M_age = 30 ± 5.8 years) were purposefully sampled and engaged in a semi-structured interview. The following four themes were generated through a reflexive thematic analysis: PA is described as important and valuable; navigating one's appearance and fitness changes after cancer treatment within the PA context; supportive care is essential to successful PA transitions; and juxtaposed environments: fitness facilities, cities, and green spaces. Developing strategies aimed at gradually transitioning into PA should be a priority to improve AYAs' well-being through survivorship.

Design and implementation of a standard care programme of therapeutic exercise and education for breast cancer survivors

BACKGROUND

Breast cancer survivors (BCS) face several symptoms and are at higher risk of weight gain following diagnosis. Current literature shows that both exercise and diet play a key role in recovery of BCS. However, there is a gap between current guidelines and the real-world context. The aim of this article is to describe the process behind a free, not-for-profit community-based therapeutic exercise and education programme (TEEP) for BCS in the clinical setting.

METHODS

The "Onco-Health Club" (OHC) consists of therapeutic exercise (TE) intervention aimed at ameliorating cancer-related fatigue (CRF) and improving QoL and physical function. TE is supplemented with nutritional education, providing information about the Mediterranean diet. To this end, patients are recruited from an oncologist and are referred to a physiotherapist and a nutritionist for baseline assessment. TEEP consists of a 3-month intervention, delivered twice a week in a group format with 1 h of TE and 30 min of nutritional education. BCS then have a final assessment and are advised to continue with a healthy lifestyle. Data about referral, compliance and assessment were collected.

RESULTS

From May 2017 to February of 2020, a total of 158 patients were recruited from 8 cohorts and 142 initially started the OHC. From 119 that joined the program, 96 patients were considered to have finished it with good adherence (assistance > 80%). BCS significantly improved their QoL, as well as upper and lower limb's function, and increased their level of physical activity. CRF tended to decrease (p = 0.005).

CONCLUSIONS

This study obtained data on recruitment, compliance, and possible limitations of these kinds of programmes in a real-world context. Further research is needed in order to optimize patient engagement and compliance, as well as to determine the transferability of these programmes in the clinical setting.

TRIAL REGISTRATION

NCT03879096, Registered 18th March 2019. Retrospectively registered.

Cancer survivors' exercise beliefs, knowledge, and behaviors: An Australian National Survey

AIMS

This study aimed to (1) explore the perceptions of people living with cancer about exercise in general and exercise as an adjunct form of cancer care, (2) explore their perceptions regarding exercise counselling needs and preferences, and (3) investigate how these perceptions of exercise as an adjunct form of cancer care shape survivors exercise levels postcancer diagnosis.

METHODS

A cross-sectional design and online survey were used to recruit cancer survivors via cancer-related networks throughout Australia. Two factor analyses were conducted to examine the structure and reduce the number of variables pertaining to exercise during and after the cancer treatment. Extracted components were used in one-way analysis of variance to compare differences in physical activity levels postcancer diagnosis.

RESULTS

Participants (N = 288) had very positive perceptions of exercise, yet only 50% of participants would prefer to receive exercise counselling. Those who were more active postcancer diagnosis had higher exercise beliefs than those who were similarly active (p = 0.04, r = 0.27) and less active (p = 0.03, r = 0.24) postdiagnosis. Those who were less active also had lower exercise knowledge than those who were similarly active (p = 0.01, r = 0.31) and more active (p = 0.03, r = 0.26). Safety beliefs did not significantly differ between cancer survivors' activity levels (p = 0.16) CONCLUSION: This survey highlights the potential benefits of a concentrated effort in connecting survivors to relevant services and resources, and utilizing cancer clinicians to communicate with survivors about the role of exercise in cancer care.

Adapting systematic scoping study methods to identify cancer-specific physical activity opportunities in Ontario, Canada

BACKGROUND

Identifying cancer-specific physical activity programs and post-secondary courses targeting students in academic settings (i.e., "real world" opportunities) may promote physical activity behaviors among cancer survivors. Using knowledge synthesis methods such as systematic scoping study methods may facilitate knowledge tool development and guide evidence-based practice to improve knowledge transfer. However, identifying these opportunities poses a challenge as systematic scoping study methods have yet to be applied and adapted to this context. Thus, to extend systematic scoping study methods, the purpose of the current investigation is to describe the adaptation of systematic scoping study methods in the context of cancer-specific "real world" opportunities in Ontario, Canada.

METHODS

Systematic scoping study methods were adapted to develop a knowledge tool, which was a credible resource website for researchers, clinicians, and survivors. Three search strategies including Advanced Google Search, targeted website search, and consultations with experts were used to identify eligible (e.g., appropriate for cancer survivors, offered in the community) cancer-specific physical activity programs. Only the targeted website search was used to search post-secondary institutions because they are centralized onto one government website.

RESULTS

Fifty-eight programs and 10 post-secondary courses met the eligibility criteria. Relevant data from these opportunities were extracted, charted, synthesized, and uploaded onto the resource website. The most successful search strategy for cancer-specific physical activity programs was the targeted website search followed by Google Advanced Search and consultations with content experts.

CONCLUSIONS

Challenges were experienced due to lack of standard reporting among opportunities, bias of potentially relevant records, and changing nature of resulting records. The current investigation demonstrated that systematic scoping study methods can be applied to cancer-specific physical activity programs and post-secondary courses in the context of cancer survivorship in Ontario yielding robust results. The method can be further adapted and updated in future knowledge syntheses in health-related contexts.

SYSTEMATIC REVIEW REGISTRATION

The systematic scoping review method protocol has not been registered.

Exercise counselling and referral in cancer care: an international scoping survey of health care practitioners' knowledge, practices, barriers, and facilitators

PURPOSE

Evidence supports the role of prescribed exercise for cancer survivors, yet few are advised to exercise by a healthcare practitioner (HCP). We sought to investigate the gap between HCPs' knowledge and practice from an international perspective.

METHODS

An online questionnaire was administered to HCPs working in cancer care between February 2020 and February 2021. The questionnaire assessed knowledge, beliefs, and practices regarding exercise counselling and referral of cancer survivors to exercise programs.

RESULTS

The questionnaire was completed by 375 participants classified as medical practitioners (42%), nurses (28%), exercise specialists (14%), and non-exercise allied health practitioners (16%). Between 35 and 50% of participants self-reported poor knowledge of when, how, and which cancer survivors to refer to exercise programs or professionals, and how to counsel based on exercise guidelines. Commonly reported barriers to exercise counselling were safety concerns, time constraints, cancer survivors being told to rest by friends and family, and not knowing how to screen people for suitability to exercise (40-48%). Multivariable logistic regression models including age, gender, practitioner group, leisure-time physical activity, and recall of guidelines found significant effects for providing specific exercise advice (χ²(7) = 117.31, p < .001), discussing the role of exercise in symptom management (χ²(7) = 65.13, p < .001) and cancer outcomes (χ²(7) = 58.69, p < .001), and referring cancer survivors to an exercise program or specialist (χ²(7) = 72.76, p < .001).

CONCLUSION

Additional education and practical support are needed to equip HCPs to provide cancer survivors with exercise guidelines, resources, and referrals to exercise specialists.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Connecting breast cancer survivors for exercise: protocol for a two-arm randomized controlled trial

BACKGROUND

Peer-based exercise interventions that cultivate new opportunities for support with a fellow cancer survivor may result in increased exercise volume. It is not clear whether adding qualified exercise professional (QEP) support to peer-based interventions improves health outcomes. Therefore, the purpose of this study is to determine whether breast cancer survivor (BCS) dyads who receive 10 weekly sessions of virtually delivered QEP support have improved outcomes compared to BCS dyads who do not receive QEP support.

METHODS

Participants Adult BCS with medical clearance for exercise, who have an internet-connected device, and currently engage in < 150 min of moderate-intensity exercise per week. Intervention BCS will be matched using evidence-based criteria. The intervention group will receive dyadic exercise information sessions and a program tailored by a QEP for 10 weeks (intervention period) and have access to the QEP for an additional 4 weeks (tapering period). The control will not receive any QEP support. Outcomes The primary outcome is post-intervention self-reported exercise volume. Secondary outcomes include device-assessed exercise volume (i.e., Fitbit), social support, and health-related quality of life. Randomization 108 participants, matched in dyads, will be randomized 1:1 to the MatchQEP or Match groups using a web-based scheme. Statistical analysis Outcomes will be measured at baseline, post-intervention, post-tapering, and at 12 weeks post-intervention follow-up.

DISCUSSION

The findings from this RCT will determine if matched BCS dyads who receive 10 weeks of virtually delivered QEP support have higher levels of self-report and device-measured exercise, social support, and health related quality of life compared to matched dyads without QEP-delivered exercise guidance. To our knowledge this will be the first study to assess the combined effect of peer- and QEP support on exercise volume. Project findings will inform and optimize intervention methods aimed to increase exercise among BCS through accessible exercise supports.

TRIAL REGISTRATION

The study is registered on ClinicalTrials.gov (study identifier: NCT04771975, protocol Version Number: 2, date: July 22, 2021).

Current Evidence and Directions for Future Research in eHealth Physical Activity Interventions for Adults Affected by Cancer: Systematic Review

Background

Physical activity (PA) interventions can increase PA and improve well-being among adults affected by cancer; however, most adults do not meet cancer-specific PA recommendations. Lack of time, facility access, and travel distances are barriers to participation in PA interventions. eHealth technologies may address some of these barriers, serving as a viable way to promote PA behavior change in this population. However, no review from July 2018 has synthesized available evidence across eHealth and cancer types or examined the use of behavioral theory and behavior change techniques (BCTs), leaving important gaps in knowledge.

Objective

This review aims to provide a comprehensive, updated overview of evidence on eHealth PA interventions for adults with cancer by describing the current state of the literature, exploring associations between intervention characteristics and effectiveness, and identifying future research needs.

Methods

MEDLINE, Embase, CINAHL, SportDiscus, Scopus, and CENTRAL were searched for eHealth PA interventions for adults affected by cancer. Study selection and data extraction were performed in duplicate, with consultation from the senior author (NCR). BCT coding, risk of bias, and completeness of reporting were performed using standardized tools. Results were summarized via narrative synthesis and harvest plots. Weight analyses were conducted to explore the associations between intervention characteristics and effectiveness.

Results

A total of 71 articles (67 studies) involving 6655 participants (mean age 56.7 years, SD 8.2) were included. Nearly 50% (32/67) of the articles were published after July 2018. Significant postintervention PA increases were noted in 52% (35/67) of the studies, and PA maintenance was noted in 41% (5/12) of the studies that included a follow-up. Study duration, primary objectives, and eHealth modality (eg, websites, activity trackers, and SMS text messaging) varied widely. Social cognitive theory (23/67, 34%) was the most used theory. The mean number of BCTs used across the studies was 13.5 (SD 5.5), with self-monitoring, credible sources, and goal setting being used in >90% of studies. Weight analyses showed the greatest associations between increased PA levels and PA as a primary outcome (0.621), interventions using websites (0.656) or mobile apps (0.563), interventions integrating multiple behavioral theories (0.750), and interventions using BCTs of problem solving (0.657) and action planning (0.645). All studies had concerns with high risk of bias, mostly because of the risk of confounding, measurement bias, and incomplete reporting.

Conclusions

A range of eHealth PA interventions may increase PA levels among adults affected by cancer, and specific components (eg, websites, use of theory, and action planning) may be linked to greater effectiveness. However, more work is needed to ascertain and optimize effectiveness, measure long-term effects, and address concerns with bias and incomplete reporting. This evidence is required to support arguments for integrating eHealth within PA promotion in oncology.

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

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

Implementing Exercise in Standard Cancer Care (Bizi Orain Hybrid Exercise Program): Protocol for a Randomized Controlled Trial

BACKGROUND

Despite the established benefits of regular exercise for patients with cancer to counteract the deleterious effects of the disease itself and treatment-related adverse effects, most of them do not engage in sufficient levels of physical activity and there is a paucity of data on the integration of efficacious exercise programs that are accessible and generalizable to a large proportion of patients with cancer into routine cancer care.

OBJECTIVE

We intend to examine the effects attributable to the implementation of a community-based exercise program on cardiorespiratory functional capacity and quality of life for patients with cancer.

METHODS

This will be a hybrid study. In the first experimental phase, patients diagnosed with any type of cancer will be randomized into two parallel groups. One group immediately performs Bizi Orain, a 3-month supervised exercise program (3 times a week), in addition to behavioral counseling in a primary health care setting; the other is a reference group that starts the exercise program 3 months later (delayed treatment). In the second observational phase, the entire cohort of participants will be followed-up for 5 years. Any person diagnosed with cancer in the previous 2 years is eligible for the program. The program evaluation involves the uptake, safety, adherence, and effectiveness assessed after completion of the program and with follow-ups at 3, 6, 12, 24, 36, 48, and 60 months. The primary outcomes of the experimental study, to be compared between groups, are improved physical function and quality of life, whereas overall survival is the main objective of the prospective study. To analyze the association between changes in physical activity levels and overall survival, longitudinal mixed-effects models will be used for repeated follow-up measures.

RESULTS

A total of 265 patients have been enrolled into the study since January 2019, with 42 patients from the hematology service and 223 from the oncology service.

CONCLUSIONS

Bizi Orain is the first population-based exercise program in Spain that will offer more insight into the implementation of feasible, generalizable, and sustainable supportive care services involving structured exercise to extend survival of patients with cancer, improve their physical function and quality of life, and reverse the adverse effects of their disease and related treatments, thereby reducing the clinical burden.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03819595; http://clinicaltrials.gov/ct2/show/NCT03819595.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24835.

Community-based exercise programs for cancer survivors: A scoping review of program characteristics using the Consolidated Framework for Implementation Research

OBJECTIVE

To describe the characteristics of exercise programs for cancer survivors conducted outside of a research laboratory (i.e., home-based, or community-based settings).

DATA SOURCES

A systematic search of published literature was conducted using Medline, Pubmed, CINAHL, PsychINFO, SPORTdiscus, and Embase from 1980 to January 2021. Where conference abstracts were identified, authors were contacted for other articles.

STUDY SELECTION

Two independent reviewers screened titles and abstracts, and full texts of potentially relevant studies with discrepancies resolved by discussion. Included studies were reports of exercise programs or interventions in which participants exercise at home, or in a community-based setting, and including individuals diagnosed with cancer either undergoing treatment or who had completed treatment.

DATA EXTRACTION

Data were extracted using the Oxford Implementation Index and coded under the five domains of the Consolidated Framework for Implementation Research (CFIR). Extraction and coding were completed by two independent reviewers, with discrepancies resolved through discussion. Data were synthesized narratively according to CFIR.

DATA SYNTHESIS

A total of 58 publications describing 34 individual programs from around the world were included. Of these, only 14 publications had the specific goal of reporting on program implementation and development. A variety of intervention characteristics and characteristics of individuals involved in the intervention were described. Reporting of factors related to the CFIR domains of inner setting, outer setting and implementation process were minimal.

CONCLUSIONS

This review summarizes the characteristics of existing programs that have been reported in the literature and finds that partnerships and collaboration in the inner and outer setting, and as part of the process of implementation. This review highlights key knowledge gaps to be answered in order to support the development of future community-based interventions.