Implementing supportive exercise interventions in the colorectal cancer care pathway: a process evaluation of the PREPARE-ABC randomised controlled trial

Background

A colorectal resection is standard treatment for patients with colorectal cancer (CRC). However, the procedure results in significant post-operative mortality and reduced quality of life. Maximising pre-operative cardiopulmonary fitness could improve post-surgical outcomes. PREPARE-ABC is a multi-centre, three-armed, randomised controlled trial investigating the effects of exercise interventions, with motivational support on short and longer-term recovery outcomes in CRC patients undergoing major lower-gastrointestinal surgery. The trial included an internal pilot phase with parallel process evaluation. The aim of the process evaluation was to optimise intervention implementation for the main trial.

Methods

Mixed methods process evaluation conducted in 14 UK hospitals between November 2016 and March 2018. Data included a site profile questionnaire and telephone scoping interview with hospital staff, 34 qualitative observations of standard care and 14 observations of intervention delivery, 13 semi-structured interviews with healthcare professionals (HCPs) and 28 semi-structured interviews with patients. Data analysis focused on describing intervention delivery within each arm, assessing fidelity, acceptability and how variation in delivery was linked to contextual characteristics.

Results

Standard care exercise advice was typically limited to maintaining current activity levels, and with lead-in time to surgery affecting whether any exercise advice was provided. Variation in HCP capacity affected the ability of colorectal units to deploy staff to deliver the intervention. Patients’ exercise history and motivation prior to surgery influenced HCP perceptions and delivery of the motivational components. Observations indicated a high level of fidelity to delivery of the exercise interventions. All but one of the 28 interviewed patients reported increasing exercise levels as a result of receiving the intervention, with most finding them motivational and greatly valuing the enhanced level of social support (versus standard care) provided by staff.

Conclusion

Hospital-supervised and home-based exercise interventions were highly acceptable for most patients undergoing surgery for CRC. Delivery of pre- and post-operative exercise within the CRC care pathway is feasible but systematic planning of capacity and resources is required to optimise implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08880-8.

Exercise intervention in cancer patients with sleep disturbances scheduled for elective surgery: Systematic review

BACKGROUND & OBJECTIVES

Sleep disturbance is one of the patients' major complaints after major surgery and can impair postoperative recovery. Pre-operative exercise has been shown to increase functional capacity and resilience in cancer patients; scarce knowledge is available on the effects of pre-operative exercise on sleep disturbances. This systematic review aims to determine the impact of pre-operative exercise training alone or as part of multimodal prehabilitation on sleep disturbances and sleep quality in cancer patients.

METHODS

A systematic search including Biosis, Cochrane Library and CENTRAL, EMBASE, MEDLINE, and clinical trial registries (clinicaltrials.gov, International Clinical Trials Registry Platform) was performed to identify studies involving a pre-operative exercise intervention in cancer patients awaiting surgery. Trials had to contain at least one sleep measure, assessed subjectively and objectively were included in the systematic review. The quality of the included trials was assessed using the Cochrane Risk of Bias Tool for assessing the risk of bias in randomized trials tool and the ROBINS-I tool for evaluating the risk of bias in non-randomized studies.

RESULTS

Seven studies were included (1 RCT, 2 non-RCTs and 4 single-arm design). Due to substantial heterogeneity in the interventions across studies, a meta-analysis was not conducted. The available empirical evidence on the presurgical effect of exercise on sleep outcomes is scarce and, overall, suggests that it has a limited effect. Besides, non-significant improvement of the pre-operative exercise on sleep was unique to the studies that used subjective measures to assess sleep disturbances changes during cancer treatment.

CONCLUSION

There are conflicting results and a lack of quality data proving the pre-operative exercise on sleep quality and disturbances. More research is needed in the pre-operative period using clinical sleep disturbances such as insomnia as an inclusion criterion, subjectively and objectively assessed.

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients: a randomised controlled trial (The EMPOWER Trial)

BACKGROUND

The EMPOWER trial aimed to assess the effects of a 9-week exercise prehabilitation programme on physical fitness compared with a usual care control group. Secondary aims were to investigate the effect of (1) the exercise prehabilitation programme on psychological health; and (2) neoadjuvant chemoradiotherapy (NCRT) on physical fitness and psychological health.

METHODS

Between October 2013 and December 2016, adults with locally advanced rectal cancer undergoing standardised NCRT and surgery were recruited to a multi-centre trial. Patients underwent cardiopulmonary exercise testing (CPET) and completed HRQoL questionnaires (EORTC-QLQ-C30 and EQ-5D-5L) pre-NCRT and post-NCRT (week 0/baseline). At week 0, patients were randomised to exercise prehabilitation or usual care (no intervention). CPET and HRQoL questionnaires were assessed at week 0, 3, 6 and 9, whilst semi-structured interviews were assessed at week 0 and week 9. Changes in oxygen uptake at anaerobic threshold (VO2 at AT (ml kg-1 min-1)) between groups were compared using linear mixed modelling.

RESULTS

Thirty-eight patients were recruited, mean age 64 (10.4) years. Of the 38 patients, 33 were randomised: 16 to usual care and 17 to exercise prehabilitation (26 males and 7 females). Exercise prehabilitation significantly improved VO2 at AT at week 9 compared to the usual care. The change from baseline to week 9, when adjusted for baseline, between the randomised groups was + 2.9 ml kg -1 min -1; (95% CI 0.8 to 5.1), p = 0.011.

CONCLUSION

A 9-week exercise prehabilitation programme significantly improved fitness following NCRT. These findings have informed the WesFit trial (NCT03509428) which is investigating the effects of community-based multimodal prehabilitation before cancer surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01914068 . Registered 1 August 2013.