Diet and exercise advice and referrals for cancer survivors: an integrative review of medical and nursing perspectives

Quality cancer survivorship care: a modified Delphi study to define nurse capabilities

PURPOSE

To establish capabilities required by nurses to deliver quality cancer survivorship care in Australia.

METHODS

A two-round online modified Delphi involving Australian cancer nurses. Initial domains and capability statements were based on the Quality of Cancer Survivorship Care Framework and supplemented by national and international nursing frameworks. In Round 1 (R1), experts categorised the applicability of 53 capabilities for cancer nurses, across eight domains, in relation to Australian National Professional Development Framework for Cancer Nursing (EdCaN) groups: 'All', 'Many', 'Some', and 'Few' nurses, or not relevant. In Round 2 (R2), experts rated agreement with capabilities allocated to the nurse groups. A priori consensus was set at ≥ 80%.

RESULTS

Surveys were distributed to 51 experts, with a response rate of 92% (47/51) for R1 and 75% (38/51) for R2. Following R1, ten capabilities were added, resulting in 63 capabilities for R2 to establish consensus allocation to EdCaN groupings. Fifty-seven capabilities reached consensus; four capabilities were moved from 'many' to 'some' nurses; one capability was moved from 'some' to 'few' nurses; and one capability was retained in 'all' nurses following Delphi feedback and research team discussion.

CONCLUSIONS

Sixty-three capabilities across eight cancer survivorship care domains were identified and allocated to different nursing groupings. This study provides important foundational work by identifying the capabilities of cancer nurses to deliver quality cancer survivorship care in Australia.

IMPLICATIONS FOR CANCER SURVIVORS

The identification of clearly defined capabilities may improve the quality of cancer survivorship care through the enrichment and standardisation of educational curricula and continuing professional education, and through improved workforce planning.

Key components for a weight management intervention for breast cancer patients - Results from a focus group study

OBJECTIVES

While weight gain after cancer diagnosis is associated with higher tumor recurrence rates, morbidity, and poorer overall survival, appropriate weight management programs are insufficiently available. This study aimed to identify the key features for a multimodal weight management intervention from patients' and healthcare professionals' (HCP) perspectives.

METHODS

Patients treated for breast cancer at the Netherlands Cancer Institute were invited to participate in one of two online focus groups; HCPs were recruited via LinkedIn and participated in a single online focus group. All three 90-minute focus groups were moderated using a semi-structured interview guide. Recordings were transcribed and coded using thematic content analysis.

RESULTS

Nine patients and seven HCPs participated. Themes applicable for patients were: 1) Absence of information; 2) Combining weight management with daily activities and responsibilities; 3) Physical and psychological side-effects; 4): Integrating weight management in treatment continuum. For HCPs, themes were: 1) Health education; 2) Integrating weight management in treatment continuum; 3) Role of healthcare insurance companies.

CONCLUSION

Multimodal lifestyle interventions designed to prevent and reduce weight gain in breast cancer patients are needed. Awareness should be raised for HCPs and patients.

PRACTICE IMPLICATIONS

For equal accessibility, cost-effective lifestyle interventions are ideally covered by healthcare insurance companies.

A qualitative descriptive study on the perspectives and experiences of multidisciplinary HCPs in providing nutritional care to older adults with cancer

OBJECTIVES

To explore the perceptions and experiences of healthcare professionals (HCPs) caring for older adults with cancer regarding dietary advice provision and dietetic referral.

METHODS

Qualitative descriptive study providing rich descriptions of the experiences of multidisciplinary HCPs in providing care to older adults with cancer, excluding dietitians or nutritionists. Purposive and snowball sampling methods were used for recruitment. Semi-structured interviews and a focus group session were conducted. Data was analysed using qualitative content analysis. Inductive codes were generated, and codes representing factors influencing HCPs' referral to dietetics and dietary advice provision were then mapped to domains in the Tailored Implementation of Chronic Diseases (TICD) checklist using a deductive approach.

RESULTS

Twenty HCPs across various Australian healthcare settings participated, with a broad range of working experience (1.5 to 53 years) being interviewed. Most participants perceived their role in the provision of general dietary advice, and there was a consensus that nutrition is important. Key barriers (e.g. lack of time and resources, perceived lack of knowledge, scope of practice), including unique patient-related barriers (e.g. co-morbidities, fatalistic mindset), and key facilitators (e.g. need for education, evidence-based resources, multidisciplinary team approach) to dietary advice provision fell within five TICD domains (intervention, health professional factors, patient factors, professional interactions, incentives and resources). Common barriers (e.g. disconnections in multidisciplinary care, lack of structured referral pathways) and facilitators (e.g. clear referral pathways) to referral fell within four TICD domains (intervention, health professional factors, professional interactions, incentives and resources).

CONCLUSION

The barriers and facilitators to referral and provision of dietary advice by HCPs suggest the need for system-level changes via a multi-pronged approach. Simple and accessible nutrition resources, stronger nutrition education for HCPs, improved referral pathways and role clarity are required to support a multidisciplinary approach to nutritional care. More qualitative research on patient-level factors involving older adults with cancer is warranted.

Health promotion nursing interventions for female breast cancer survivors: A scoping review

AIM

Map the existing health promotion nursing interventions for female breast cancer survivors (BCS) to describe the approaches used and the characteristics of these interventions in the available studies.

DESIGN

A scoping review.

DATA SOURCE

Five electronic databases were systematically searched for eligible studies, published between 2002 and 2022.

METHODS

Following the Joanna Briggs Institute's methodology, two reviewers independently used Covidence to screen the title, abstract and full text of evidence against the inclusion criteria and extracted data using an extraction table. The PRISMA Extension for Scoping Reviews (PRISMA-ScR) guided the reporting. No patient or public contribution was necessary.

RESULTS

This review included 22 studies on nursing health promotion interventions for BCSs, primarily conducted in specialized care centres. In 20 of 22 studies, nurses employed the educational approach to promote the health of BCSs. Many interventions aimed to support survivors in adopting healthy lifestyles, improving their sexual health, promoting overall well-being and addressing their individual needs by equipping them with self-care skills. Nurses utilized self-monitoring, health education materials and technologies to support survivors' health.

CONCLUSION

The review concludes that the nurse used various approaches and interventions with different characteristics to improve the health of BCSs. This review also emphasizes that a limited number of determinants of health have been considered by nurses in the development of health promotion interventions.

IMPACT

The review highlights the important role that nurses can play in enhancing the health of female BCSs after cancer treatments. This review can guide future research for developing nursing health promotion interventions in primary care settings for female BCSs. Additionally, the review offers insights to support future research, education and training on diverse approaches and characteristics that nurses can utilize to establish interventions that enhance the health of female BCSs.

Impact of Dietitian-Delivered Motivational Interviewing Within a Food is Medicine Intervention Targeting Adults Living With and Beyond Cancer

Food is medicine (FIM) interventions are a strategy for preventing and managing chronic disease via diet. These interventions often combine the provision of food with access to behavior change support (e.g., from registered dietitians (RDs)), though the ideal approach for the latter is not fully elucidated. The objective of this study is to evaluate integrated motivational interviewing (MI) from an RD (RDMI) on outcomes among adults living with and beyond cancer (LWBC) with overweight and obesity enrolled in a FIM intervention (Clinicaltrials.gov: NCT03489213 (02/09/2018)). Specifically, RDMI with autonomy in the mode of delivery (i.e., phone, email, text, video) and dose (frequency) was offered within a 6-month intensive FIM intervention followed by a 6-month step-down maintenance phase. Dose and engagement with RDMI were measured. There were 52 and 33 participants who requested RDMI during the intensive and maintenance phases, respectively. Completion of ≥ 1 RDMI telephonic encounter significantly predicted weight loss post-intervention (R2 = 0.07, p = 0.03); there were no differences in dose, engagement, or weight loss based on the mode of delivery. The dose during the intensive intervention was moderately and significantly correlated with weight loss post-intervention and maintenance (r = 0.43, p < 0.01; r = 0.33, p = 0.02, respectively); there was a weak correlation for engagement at the same follow-up points (r = 0.28 and r = 0.15). In conclusion, higher doses of RDMI improved weight loss for adults LWBC with overweight or obesity. Careful consideration of the implementation of MI from providers, including RDs, in the context of cancer-focused FIM interventions should be further examined.

Cancer survivors' adherence to the American cancer society and American institute of cancer research dietary guidelines in Lebanon

BACKGROUND

Adequate diet and lifestyle practices are postulated to improve health and enhance wellbeing of cancer survivors. Despite the heavy cancer burden in Lebanon, little is known about the diet quality of survivors. This cross-sectional study assessed the compliance of survivors in remission with the American Cancer Society/American Institute Research Fund (ACS/AICR) diet and physical activity guidelines.

METHODS

Cancer survivors in remission for at least 3 months and attending oncology clinics in two referral centers in Beirut, Lebanon were recruited. Adherence to the ACS/AICR was assessed by examining the compliance to guidelines promoting fruits, vegetables and whole grain and discouraging elevated alcohol, meat and energy dense foods intake. Dietary data was assessed through food frequency and lifestyle questionnaires administered face to face and through phone interviews. Anthropometrics, food security and sociodemographic data was also collected. Univariate and bivariate descriptive and logistic regressions were used to determine predictors of adherence rates to the ACS/AICR score.

RESULTS

A total of 268 participants were recruited (mean age = 59 ± 23 years, 83% females, 70% breast cancer). Mean time since remission was 3.2 ± 4 years and the majority (72%) had food insecurity. Low physical activity and overweight/obesity were present in 65% and 67% of the survivors, respectively. Median adherence score with the ACS/AICR score was 9.0 out of 15. The majority of survivors had complete adherence to the moderate meat and alcohol consumption guidelines. However, 98% were noncompliant with the whole grains' consumption guidelines. Cancer type, site of recruitment and education were the significant predictors of the ACS/AICR diet adherence score.

CONCLUSION

This study highlights the elevated rates of overweight/obesity, physical inactivity and the alarmingly low adherence with the whole grains consumption guideline among cancer survivors in remission. Policy makers ought to use study findings to redirect government subsidization and educational interventions in the country and physicians should stress the importance of adherence to a healthy diet during remission through counseling and timely referral.

Post-diagnosis dietary factors, supplement use and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

The role of diet in colorectal cancer prognosis is not well understood and specific lifestyle recommendations are lacking. We searched for randomised controlled trials (RCTs) and longitudinal observational studies on post-diagnosis dietary factors, supplement use and colorectal cancer survival outcomes in PubMed and Embase from inception until 28th February 2022. Random-effects dose-response meta-analyses were conducted when at least three studies had sufficient information. The evidence was interpreted and graded by the CUP Global independent Expert Committee on Cancer Survivorship and Expert Panel. Five RCTs and 35 observational studies were included (30,242 cases, over 8700 all-cause and 2100 colorectal cancer deaths, 3700 progression, recurrence, or disease-free events). Meta-analyses, including 3-10 observational studies each, were conducted for: whole grains, nuts/peanuts, red and processed meat, dairy products, sugary drinks, artificially sweetened beverages, coffee, alcohol, dietary glycaemic load/index, insulin load/index, marine omega-3 polyunsaturated fatty acids, supplemental calcium, circulating 25-hydroxyvitamin D (25[OH]D) and all-cause mortality; for alcohol, supplemental calcium, circulating 25(OH)D and colorectal cancer-specific mortality; and for circulating 25(OH)D and recurrence/disease-free survival. The overall evidence was graded as 'limited'. The inverse associations between healthy dietary and/or lifestyle patterns (including diets that comprised plant-based foods), whole grains, total, caffeinated, or decaffeinated coffee and all-cause mortality and the positive associations between unhealthy dietary patterns, sugary drinks and all-cause mortality provided 'limited-suggestive' evidence. All other exposure-outcome associations provided 'limited-no conclusion' evidence. Additional, well-conducted cohort studies and carefully designed RCTs are needed to develop specific lifestyle recommendations for colorectal cancer survivors.

Adopting a systems-thinking approach to optimise dietary and exercise referral practices for cancer survivors

PURPOSE

Service referrals are required for cancer survivors to access specialist dietary and exercise support. Many system-level factors influence referral practices within the healthcare system. Hence, the aim of this study was to identify system-level factors and their interconnectedness, as well as strategies for optimising dietary and exercise referral practices in Australia.

METHODS

A full-day workshop involving national multidisciplinary key stakeholders explored system-level factors impacting dietary and exercise referral practices. Facilitated group discussions using the nominal group technique identified barriers and facilitators to referral practices based on the six World Health Organisation (WHO) building blocks. The systems-thinking approach generated six cognitive maps, each representing a building block. A causal loop diagram was developed to visualise factors that influence referral practices. Additionally, each group identified their top five strategies by leveraging facilitators and addressing barriers relevant to their WHO building block.

RESULTS

Twenty-seven stakeholders participated in the workshop, including consumers (n = 2), cancer specialists (n = 4), nursing (n = 6) and allied health professionals (n = 10), and researchers, representatives of peak bodies, not-for-profit organisations, and government agencies (n = 5). Common system-level factors impacting on referral practices included funding, accessibility, knowledge and education, workforce capacity, and infrastructure. Fifteen system-level strategies were identified to improve referral practices.

CONCLUSION

This study identified system-level factors and strategies that can be applied to policy planning and practice in Australia.

Pre-Frailty and Frailty in Hospitalized Older Adults: A Comparison Study in People with and without a History of Cancer in an Acute Medical Unit

A prospective observational study was conducted in a cohort of older adults ≥65 years (n = 329), admitted to the acute medical unit (AMU) of a tertiary hospital, to describe and compare characteristics including frailty status and clinical outcomes. Multivariable models compared older adults with and without a history of cancer to determine characteristics associated with frailty and pre-frailty. An adjusted Poisson regression model was used to compare the length of hospital stay (LOS) between the two groups. About one-fifth (22%) of the cohort had a history of cancer. The most common cancer types were prostate (n = 20), breast (n = 13), lung (n = 8) and gastrointestinal (n = 8). There was no difference in the prevalence of pre-frailty/frailty among patients with or without a history of cancer (58% vs. 57%, p > 0.05). Pre-frailty/frailty was associated with polypharmacy (OR 8.26, 95% CI: 1.74 to 39.2) and malnutrition (OR 8.91, 95% CI: 2.15 to 36.9) in patients with a history of cancer. Adjusted analysis revealed that the risk of having a longer LOS was 24% higher in older adults with a history of cancer than those without (IRR 1.24, 95% CI 1.10 to 1.41, p < 0.001). Clinicians in the AMU should be aware that older adults with a history of cancer have a higher risk of a longer LOS compared to those without.

Current Oncology Nutrition Care Practice in Southeast Asia: A Scoping Review

Although evidence-based nutrition care is recommended for patients with cancer, current nutrition care practices provided by nutritionists and dietitians in Southeast Asian countries are not clearly reported. The aim of this scoping review was to describe nutritionists' and dietitians' current oncology nutrition care practice within Southeast Asia by identifying access to dietetic services, tools or strategies used in providing care, and barriers and enablers to implementing nutrition care practices. Five databases (Ovid MEDLINE, Global Health, Embase, Cochrane Central Register of Controlled Trials, and Proquest) were searched through structured search strategies, in addition to strategic searching of grey literature. A total of 4261 sources of evidence were retrieved. After full-text screening, 18 studies from Southeast Asian countries met the inclusion criteria and were included in this review. The provision and reporting of nutrition care practices provided by nutritionists and dietitians were limited. Access to dietetic services, including nutritional screening tools and reason to be referred, were varied within studies. Barriers and enablers to nutrition care provision were unique and related to each country's specific resources and guidelines. In summary, there was varied reporting of nutrition care practices provided to patients with cancer in Southeast Asia and a lack of clarity on the actual standardized processes. Future research is warranted to further explore the barriers and enablers to providing nutrition care by local nutritionists and dietitians in Southeast Asia.

The feasibility and acceptability of an app-based intervention with brief behavioural support (APPROACH) to promote brisk walking in people diagnosed with breast, prostate and colorectal cancer in the UK

INTRODUCTION

Increased moderate to vigorous physical activity (MVPA) can improve clinical and psychosocial outcomes for people living with and beyond cancer (LWBC). This study aimed to assess the feasibility and acceptability of trial procedures in a pilot randomised controlled trial (RCT) of a theory-driven app-based intervention with behavioural support focused on promoting brisk walking (a form of MVPA) in people LWBC (APPROACH).

METHODS

Participants diagnosed with breast, prostate or colorectal cancer were recruited from a single UK hospital site. Assessments at baseline and 3 months included online questionnaires, device-measured brisk walking (activPAL accelerometer) and self-reported weight and height. Participants were randomised to intervention or control (care as usual). The intervention comprised a non-cancer-specific app to promote brisk walking (National Health Service 'Active 10') augmented with print information about habit formation, a walking planner and two behavioural support telephone calls. Feasibility and acceptability of trial procedures were explored. Initial estimates for physical activity informed a power calculation for a phase III RCT. A preliminary health economics analysis was conducted.

RESULTS

Of those medically eligible, 369/577 (64%) were willing to answer further eligibility questions and 90/148 (61%) of those eligible were enrolled. Feasibility outcomes, including retention (97%), assessment completion rates (>86%) and app download rates in the intervention group (96%), suggest that the trial procedures are acceptable and that the intervention is feasible. The phase III RCT will require 472 participants to be randomised. As expected, the preliminary health economic analyses indicate a high level of uncertainty around the cost-effectiveness of the intervention.

CONCLUSIONS

This pilot study demonstrates that a large trial of the brisk walking intervention with behavioural support is both feasible and acceptable to people LWBC. The results support progression onto a confirmatory phase III trial to determine the efficacy and cost-effectiveness of the intervention.

Determinants of lifestyle and body weight status among breast cancer survivors with overweight/obesity and perspectives towards the development of weight loss interventions: a qualitative study with health professionals from Greece

The current study assessed the views and attitudes of health professionals (HPs) regarding factors associated with energy balance-related health behaviours and weight management in breast cancer survivors (BCS) with overweight and obesity. Semi-structured online interviews were conducted with 21 HPs (oncologists, dietitians- nutritionists, physical education instructors, mental health professionals, and nurses) from Attica and Thessaly. Thematic analysis was used to analyse and present the data. Four main themes arose from the data: "The patients' mental health wellbeing", "Survivors' interest in diet and exercise", "Interdisciplinary collaboration in patient's care", and "Maintaining normality". HPs agreed that weight loss in BCS with overweight and obesity is important, but negative mental health wellbeing is a main barrier to behaviour change. For many BCS their cancer diagnosis is a "teachable" moment for weight management, especially for women of younger age, who are more keen to discuss weight management issues. Essential characteristics that determine/facilitate behavioural change include education, commitment for regular communication, personalised intervention, and interdisciplinary collaboration. According to HPs, future weight loss interventions should take into account BCS's mental health wellbeing and level of motivation and should provide regular support and education.

Evaluating the psychometric properties of the Persian version of the Healthy Lifestyle Instrument for Breast Cancer Survivors (HLI-BCS)

BACKGROUND

Precise examination of breast cancer survivors' lifestyles can lead to improved planning and implementation of care and counseling interventions to increase their survival rate and improve their quality of life. Therefore, a valid and reliable instrument needs to be developed. Therefore, the present study aimed to determine the psychometric properties of the Persian version of the Healthy Lifestyle Instrument for Breast Cancer Survivors (HLI-BCS).

METHODS

This methodological study was conducted on 420 Iranian breast cancer survivors between May and November 2022. Participants were selected using convenience sampling. The face, content, construct validity, convergent, and reliability of the Persian version of the HLI-BCS were assessed.

RESULTS

After assessing face, content, and construct validity, the Persian version of the HLI-BCS with five factors and 20 items was provided. The total Cronbach's alpha and intra-class correlation coefficient (ICC) were calculated as 0.86 and 0.79, respectively, which were at acceptable levels. A healthy lifestyle in breast cancer survivors was observed to have strong and significant relationships with quality of life in general (p < 0.001, r = 0.832), physical health (r = 0.786), and mental health (r = 0.809).

CONCLUSION

The Persian version of the HLI-BCS has favorable properties, is consistent with the conditions of breast cancer survivors, and is valid and reliable. This version of the scale can provide adequate and precise information on the lifestyles of these patients.

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.