Cancer survivors’ attitudes towards and knowledge of physical activity, sources of information, and barriers and facilitators of engagement: A qualitative study

Experiences, behaviours, and perspectives of young cancer survivors on physical activity

This narrative review aimed to identify young cancer survivors' behaviours, experiences, and perspectives concerning physical activity, and identify useful strategies for promoting a healthy lifestyle. A manual search on the following databases was conducted: PubMed, Scopus, and Web of Science. The search was conducted between June 1, 2023, and April 12, 2024. Articles published from database inception up to April 12, 2024, were retrieved. Articles published in any language were considered. Perspectives including ideas, perceived barriers, and facilitators have been identified. Young cancer survivors seem to engage in physical activity as a useful coping strategy to regain normality and keep healthy after the cancer diagnosis. Although emotional and social support seems fundamental to increase participation, several other factors, including physical limitations, fatigue, sex, cancer type, and socio-economic status can influence physical activity participation. For those engaged in physical activity, the preferred activities are walking, biking, going to the gym, and exercising at home, while the least preferred are exercising at the hospital or boot camp-based exercises. Yoga is more frequently chosen by those still under treatment. Young cancer survivors appear to have unique needs different from those of adult cancer survivors. Mode of treatment delivery, increased awareness concerning the effects of physical activity, including families and friends, connecting survivors, and providing social support together with increasing motivation are key strategies for the promotion of physical activity in young cancer survivors. Fitness and healthcare professionals should consider these aspects to increase young cancer survivors' involvement in physical activities.

Post-diagnosis physical activity and sedentary behaviour and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

Low physical activity and high sedentary behaviour have been clearly linked with colorectal cancer development, yet data on their potential role in colorectal cancer survival is limited. Better characterisation of these relationships is needed for the development of post-diagnosis physical activity and sedentary behaviour guidance for colorectal cancer survivors. We searched PubMed and Embase through 28 February 2022 for studies assessing post-diagnosis physical activity, and/or sedentary behaviour in relation to all-cause and cause-specific mortality and recurrence after colorectal cancer diagnosis. Total and recreational physical activity were assessed overall and by frequency, duration, intensity, and volume using categorical, linear, and non-linear dose-response random-effects meta-analyses. The Global Cancer Update Programme (CUP Global) independent Expert Committee on Cancer Survivorship and Expert Panel interpreted and graded the likelihood of causality. We identified 16 observational studies on 82,220 non-overlapping patients from six countries. Physical activity was consistently inversely associated with colorectal cancer morbidity and mortality outcomes, with 13%-60% estimated reductions in risk. Sedentary behaviour was positively associated with all-cause mortality. The evidence had methodological limitations including potential confounding, selection bias and reverse causation, coupled with a limited number of studies for most associations. The CUP Global Expert panel concluded limited-suggestive evidence for recreational physical activity with all-cause mortality and cancer recurrence. Total physical activity and its specific domains and dimensions, and sedentary behaviour were all graded as limited-no conclusion for all outcomes. Future research should focus on randomised trials, while observational studies should obtain objective and repeated physical activity measures and better adjustment for confounders.

[Barriers and facilitators to physical activity in oncology in Seine-Saint-Denis: A qualitative study using the socio-ecological approach]

INTRODUCTION

Despite the undeniable benefits of physical activity during and beyond cancer treatments, patients do not always undertake and/or maintain it. The aim of the study is to identify, describe and understand the barriers and facilitators of physical activity practice among adults arriving at the end of treatment for solid cancer, in precarious situations, living in Seine-Saint-Denis.

METHODS

The study was conducted using a descriptive qualitative phenomenological method involving semi-directed interviews with 23 participants during and beyond cancer.

RESULTS

Multiple-level factors (micro, meso, macro) are involved in active behavior of patients. Three main facilitators were identified: perceived benefit, social support, and urban planning. Three barriers are identified: (1) physical and psychological disorders whether or not related to cancer and its treatment, (2) precariousness, organizational constraints, unfavorable social environment, (3) lack of coordination, lack of accurate and appropriate information, lack of realistic referral to physical activity offers.

DISCUSSION

A diversity of representations, combinations of factors, and experiences are described. Getting people with cancer to engage in and maintain long-term physical activity is a complex task, requiring multidisciplinary action on all socio-ecological factors.

Facilitators and barriers of attending BaDuanJin experienced by breast cancer survivors during chemotherapy

PURPOSE

This study aimed to identify facilitators and barriers to adherence to a Baduanjin program experienced by breast cancer survivors (BCSs) during chemotherapy.

METHODS

Semi-structured interviews with 10 BCSs in an interprofessional BaDuanJin program were conducted to understand their experiences, including the facilitators and barriers concerning exercise. Content analysis was performed following the behaviour change wheel (BCW).

RESULTS

The following five domains emerged from the analysis: 1) Capacity: Recovery of upper limb function, symptom relief, and emotional release are facilitators; periodic treatment and related symptoms and negative emotions are barriers; 2) Motivation: Reflection on health, positive belief, and weight control are facilitators; a doubtful attitude is a barrier; 3) Opportunity: Recuperating at home is a facilitator; 4) Intervention: Facilitators include simple and gentle exercise at home, comprehensive tutoring by an interprofessional team, treating exercise as a task occurring at a fixed time, and peer support. The hindrances are work and home duties prior to exercise and a lack of group activities; and 5) Policy: Social media promotion and less support from physicians are facilitators and barriers, respectively.

CONCLUSION

Identifying facilitators and barriers leads to improved support from health professionals, which is required to provide effective strategies to increase adherence to BaDuanJin exercise.

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.

Understanding experience, knowledge and perceived challenges related to bra fit for sports participation: a scoping review

The breasts are reported as the fourth largest barrier to participation in physical activity (PA). This scoping review provides a comprehensive understanding of experiences, knowledge and challenges relating to bra fit and sports participation. The search strategy was adopted by the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) guidelines and multiple databases were searched. All research was in English and within the last 20 years. Exclusion criteria excluded reviews, male participants and the inability to locate or access full-text articles. The JBI critical appraisal tool assessed methodological quality. Twenty-three studies were included. Key themes from the studies are breast motion during PA, sports bra design, perceived barriers to participation in PA and education/knowledge of breast support and bra fit. Increasing breast support reduces breast movement during PA yet breast motion and bra fit are still the most common breast concerns for females. This is likely influenced by poor breast knowledge, leading to poor breast support choices. Future research should explore to what extent breast motion, knowledge and bra fit influences sport participation, and this research should include a more diverse range of adult ages, cup sizes, ethnicities and PA levels to provide a wider understanding.

Reflective Engagement With a Digital Physical Activity Intervention Among People Living With and Beyond Breast Cancer: Mixed Methods Study

BACKGROUND

People living with and beyond breast cancer can face internal barriers to physical activity (eg, fatigue and pain). Digital interventions that promote psychological acceptance and motivation may help this population navigate these barriers. The degree to which individuals (1) adhere to intervention protocols and (2) reflect on and internalize intervention content may predict intervention efficacy.

OBJECTIVE

The objective of this study was to characterize the nature of reflective processes brought about by an 8-week acceptance- and mindfulness-based physical activity intervention for insufficiently active survivors of breast cancer (n=75). Furthermore, we explored the potential utility of a metric of reflective processes for predicting study outcomes.

METHODS

Of the intervention's 8 weekly modules, 7 (88%) included an item that asked participants to reflect on what they found to be most useful. Two coders conducted directed content analysis on participants' written responses. They assessed each comment's depth of reflection using an existing framework (ranging from 0 to 4, with 0=simple description and 4=fundamental change with consideration of social and ethical issues). The coders identified themes within the various levels of reflection. We fit multiple linear regression models to evaluate whether participants' (1) intervention adherence (ie, number of modules completed) and (2) the mean level of the depth of reflection predicted study outcomes.

RESULTS

Participants were aged on average 57.2 (SD 11.2) years, mostly non-Hispanic White (58/75, 77%), and mostly overweight or obese (54/75, 72%). Of the 407 responses to the item prompting personal reflection, 70 (17.2%) were rated as reflection level 0 (ie, description), 247 (60.7%) were level 1 (ie, reflective description), 74 (18.2%) were level 2 (ie, dialogic reflection), 14 (3.4%) were level 3 (ie, transformative reflection), and 2 (0.5%) were level 4 (ie, critical reflection). Lower levels of reflection were characterized by the acquisition of knowledge or expressing intentions. Higher levels were characterized by personal insight, commentary on behavior change processes, and a change of perspective. Intervention adherence was associated with increases in self-reported weekly bouts of muscle-strengthening exercise (B=0.26, SE 0.12, 95% CI 0.02-0.50) and decreases in sleep disturbance (B=-1.04, SE 0.50, 95% CI -0.06 to -2.02). The mean level of reflection was associated with increases in psychological acceptance (B=3.42, SE 1.70, 95% CI 0.09-6.75) and motivation for physical activity (ie, integrated regulation: B=0.55, SE 0.25, 95% CI 0.06-1.04).

CONCLUSIONS

We identified a useful method for understanding the reflective processes that can occur during digital behavior change interventions serving people living with and beyond breast cancer. Intervention adherence and the depth of reflection each predicted changes in study outcomes. Deeper reflection on intervention content was associated with beneficial changes in the determinants of sustained behavior change. More research is needed to investigate the relations among digital behavior change intervention use, psychological processes, and intervention efficacy.

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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Barriers to and facilitators of physical activity in adults living with and beyond cancer, with special emphasis on head and neck cancer: a systematic review of qualitative and mixed methods studies

PURPOSE

Physical activity can improve health outcomes for cancer patients; however, only 30% of patients are physically active. This review explored barriers to and facilitators of physical activity promotion and participation in patients living with and beyond cancer. Secondary aims were to (1) explore similarities and differences in barriers and facilitators experienced in head and neck cancer versus other cancers, and (2) identify how many studies considered the influence of socioeconomic characteristics on physical activity behaviour.

METHODS

CINAHL Plus, MEDLINE, PsycINFO, Scopus and Cochrane (CDSR) were searched for qualitative and mixed methods evidence. Quality assessment was conducted using the Mixed Methods Appraisal Tool and a Critical Appraisal Skills Programme Tool. Thematic synthesis and frequency of reporting were conducted, and results were structured using the Capability-Opportunity-Motivation-Behaviour model and Theoretical Domains Framework.

RESULTS

Thirty qualitative and six mixed methods studies were included. Socioeconomic characteristics were not frequently assessed across the included studies. Barriers included side effects and comorbidities (physical capability; skills) and lack of knowledge (psychological capability; knowledge). Having a dry mouth or throat and choking concerns were reported in head and neck cancer, but not across other cancers. Facilitators included improving education (psychological capability; knowledge) on the benefits and safety of physical activity.

CONCLUSION

Educating patients and healthcare professionals on the benefits and safety of physical activity may facilitate promotion, uptakeand adherence. Head and neck cancer patients experienced barriers not cited across other cancers, and research exploring physical activity promotion in this patient group is required to improve physical activity engagement.

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.

Fatigue, quality of life and associations with adherence to the World Cancer Research Fund guidelines for health behaviours in 5835 adults living with and beyond breast, prostate and colorectal cancer in England: A cross-sectional study

BACKGROUND

Many individuals living with and beyond cancer (LWBC) have ongoing quality of life (QoL) issues, including fatigue. The World Cancer Research Fund (WCRF) provides health behaviour recommendations for people LWBC, and there is some evidence linking adherence to these with improved QoL.

METHODS

Adults LWBC (specifically breast, colorectal or prostate cancer) completed a survey covering health behaviours (diet, physical activity, alcohol consumption and smoking), fatigue (FACIT-Fatigue Scale, version 4) and a broad measure of QoL (EQ-5D-5L descriptive scale). Participants were categorised as meeting/not meeting WCRF recommendations, using the following cut-offs classified as meeting the guidelines: ≥150 min physical activity/week, fruit and vegetables (≥5 portions/day), fibre (≥30 g fibre per day), free sugar (<5% of total calories from free sugar), fat (<33% total energy), red meat (<500 g/week), processed meat (none), alcohol consumption (<14 units/week) and not a current smoker. Logistic regression analyses explored associations between WCRF adherence and fatigue and QoL issues, controlling for demographic and clinical variables.

RESULTS

Among 5835 individuals LWBC (mean age: 67 years, 56% female, 90% white, breast 48%, prostate 32% and colorectal 21%), 22% had severe fatigue and 72% had 1+ issue/s on the EQ-5D-5L. Adhering to physical activity recommendations (odds ratio [OR] = 0.88, confidence interval [CI] = 0.77-0.99), meeting various dietary recommendations (fruit and vegetables OR = 0.79; CI = 0.68-0.91, free sugar OR = 0.85; CI = 0.76-0.96, fat OR = 0.71; CI = 0.62-0.82, red meat OR = 0.65; CI = 0.50-0.85) and not smoking (OR = 0.53, CI = 0.41-0.67) were associated with decreased odds of experiencing severe fatigue. Adhering to physical activity guidelines (OR = 0.71, CI = 0.62-0.82) was also associated with decreased odds of having 1+ QoL issue/s.

CONCLUSIONS

Adherence to various WCRF recommendations, particularly the recommendation for physical activity, was associated with less fatigue and better QoL in a large UK cohort of people living with and beyond breast, colorectal or prostate cancer. Multi-component interventions designed to support people LWBC to improve health behaviours, in line with the levels recommended by the WCRF, may also improve QoL.

A multimodal interdisciplinary rehabilitation programme (HAPPY) for patients undergoing allogeneic non-myeloablative haematopoietic stem cell transplantation: A feasibility study

PURPOSE

To evaluate the feasibility of the multimodal interdisciplinary rehabilitation programme HAPPY, targeting patients with haematological malignancy and undergoing allogeneic non-myeloablative haematopoietic stem cell transplantation (NMA-HSCT).

METHOD

A single arm longitudinal design was applied to test the feasibility of the 6-month HAPPY programme, which consisted of motivational interviewing dialogues, individual supervised physical exercise training, relaxation exercises, nutritional counselling, and home assignments. The feasibility measures included acceptability, fidelity, exposure, practicability, and safety. Descriptive statistics were conducted.

RESULTS

From November 2018 to January 2020, thirty patients (mean age (SD) 64.1 (6.5)) were enrolled in HAPPY, of whom 18 patients completed the programme. Acceptance was 88%; attrition 40%; fidelity was 80%-100% for all HAPPY elements except phone calls; exposure of HAPPY elements at the hospital reflected individual differences but was acceptable, whereas exposure of HAPPY elements at home was low. Planning of HAPPY for the individual patient was time consuming, and patients were dependent of reminders and incites from the health care professionals.

CONCLUSION

Most elements of the rehabilitation programme HAPPY were feasible. Yet, HAPPY will benefit from further development and simplifications before an effectiveness study can be conducted, especially regarding improvement of the intervention elements supporting patients at home.

Correlates of Physical Activity Participation among Individuals Diagnosed with Cancer: An Application of the Multi-Process Action Control Framework

BACKGROUND

The purpose of this study was to test Multi-Process Action Control (M-PAC) processes as correlates of physical activity (PA) intention formation and translation (i.e., action control) in individuals diagnosed with cancer.

METHODS

This study was a cross-sectional survey, completed from July to November of 2020 during the COVID-19 pandemic. PA and M-PAC processes were self-reported using the Godin Leisure-Time Exercise Questionnaire and questionnaires for reflective (instrumental/affective attitudes, perceived opportunity/capability), regulatory (e.g., goal-setting, planning), and reflexive processes (habit, identity). Separate hierarchical multinomial logistic regression models determined correlates of intention formation and action control.

RESULTS

Participants (n = 347; M_age= 48.2 ± 15.6) were primarily diagnosed with breast cancer (27.4%) and at a localized stage (85.0%). Most participants intended to perform PA (70.9%), yet only 50.4% met guidelines. Affective judgements (p < 0.001) and perceived capability (p < 0.01) were significantly associated with intention formation. Preliminary models indicated employment, affective judgements, perceived capability, and self-regulation to be significant (ps < 0.05) correlates of action control, but in the final model, only surgical treatment (p = 0.02) and PA identity (p < 0.001) were significantly associated with action control.

CONCLUSION

Reflective processes were associated with PA intention formation, while reflexive processes were associated with PA action control. Behavior change efforts for individuals diagnosed with cancer should extend beyond social-cognitive approaches to include regulatory and reflexive processes of PA behavior (i.e., PA identity).

Beliefs and interests in physical activity programs of cancer survivors and their romantic partners

PURPOSE

Physical activity is associated with improved health outcomes for cancer survivors and their romantic partners, yet it is unclear if joint exercise programs for survivor-partner dyads are acceptable. This study examined demographic, relationship, exercise, and cancer history correlates of survivors' and their romantic partners' couples-based exercise beliefs and their preferences for program designs.

METHODS

All participants (survivors n=209, partners n=155, couples n=143) completed an online survey. Correlations and linear regression analyses were used to examine correlates of participants' importance of and interest in couples-based exercise and their likelihood of joining a couples-based exercise program. Intraclass correlations estimated shared variance at the couple level.

RESULTS

Most participants believed that couples-based exercise was highly important (51.8%) and were interested in a couples-based exercise program (61.5%), but fewer survivors believed their partner would be interested or would likely join a couples-based program. Across all outcomes, partner support for exercise was most strongly associated with participants' couples-based exercise beliefs (r = 0.19-0.54, p<.05), and couples were significantly aligned in their beliefs (ρ=0.20-0.31, p<.01). Participants were interested in exercise programs involving exercising together (67.3%) as well as exercising separately while sharing activity data on an app or website (48.0%).

CONCLUSIONS

This novel understanding of couples-based exercise beliefs provides a strong foundation upon which future exercise programs may be designed for survivors and their romantic partners.

IMPACT FOR CANCER SURVIVORS

Survivors' adoption and maintenance of exercise may be enhanced by the inclusion of romantic partners in exercise programs, and partners' inclusion is appealing to couples.

What information can we gain from the quality appraisal of guidelines with physical activity recommendations for cancer patients?A systematic review using the AGREE II and AGREE-REX tools

PURPOSE

There has been growing amount of evidence supporting the benefits of physical activity (PA) on oncological patients' cancer-related health outcomes. Although guidelines on cancer rehabilitation are widely available, the varying quality and practical applicability limited the clinical application of PA recommendations. To assist the future development of guidelines, in this systematic review, we evaluated the quality and applicability of current cancer rehabilitation guidelines with PA recommendations and synthesized PA recommendations for the oncological population.

METHODS

A systematic search was conducted in PubMed, CINAHL, PEDro, EMBASE, and guideline repositories to identify guidelines with PA recommendations for cancer patients from 1 May 2016 to 1 June 2022. The quality of included guidelines was appraised using the tools "Appraisal of Guidelines for Research and Evaluation II" (AGREE II) and AGREE-REX (Recommendation Excellence). PA recommendations were synthesized from the guidelines.

RESULTS

Sixteen guidelines were extracted. The AGREE II domain "clarity of presentation" obtained the highest score, while "applicability" received the lowest, ranging from 33.33% to 98.58%. The AGREE-REX domains "values and preferences" and "implementability" generally scored lower and ranged from 45.83% to 74.17% and 55% to 88.33%, respectively. Eight high-quality guidelines were identified, and the included PA recommendations were extracted.

CONCLUSION

There were some disparities in the quality of the included guidelines. Methodological weaknesses were commonly observed in domains "applicability," "values and preferences," and "implementability"; particular attention should be given to these domains when developing future guidelines. Furthermore, this analysis indicated that more rigorous, high-quality studies are needed to generate evidence for supporting PA recommendations and provide guidance on research gaps in the field of cancer rehabilitation.

How do I deal with breast cancer: a qualitative inquiry into the coping strategies of Iranian women survivors

Background

Breast cancer is the most frequent cancer in Iran. Understanding the coping strategies employed by cancer survivors can provide valuable information for designing interventions to help them adapt to the problems produced by cancer and its treatment. This study aimed to explore the coping strategies of BC survivors in Iran.

Methods

This qualitative study was conducted in Mashhad, Northeast Iran, between April and December 2021. Fourteen BC survivors were selected through purposive sampling. The data were collected using semi-structured interviews. Data were analyzed using conventional content analysis adopted by Graneheim and Lundman. MAXQDA 12 software was used for data organization. Components of trustworthiness, including credibility, dependability, confirmability, and transferability, were considered.

Results

The main categories that emerged from the participants' data analysis were “behavioral coping strategies” and “emotional coping strategies.” Behavioral coping strategies included efforts to adopt healthy nutrition, attempts to improve a healthy lifestyle, maintenance of everyday activities, use of specialized cancer support consultation services, and seeking to increase health literacy about BC. The emotional coping strategies consisted of denial as a temporary escape route, positive thinking and focusing on the positive aspects of life, reinforcement of spirituality, and seeking the support of relatives.

Conclusion

Our findings provide an in-depth understanding of Iranian women’s strategies for coping with BC. A trained team of oncologists, psychiatrists, mental health professionals, and reproductive health specialists needs to contribute significantly to improving the coping ability of patients with cancer, which could lead to enhanced health promotion and a higher quality of life.

A qualitative study to explore the acceptability and usefulness of personalized biofeedback to motivate physical activity in cancer survivors

Objective

Many cancer survivors do not meet recommended levels of exercise, despite the benefits physical activity offers. This study aimed to understand experiences of insufficiently active overweight/obese breast or colorectal cancer survivors, in efforts to (1) examine regular physical activity barriers, and (2) determine perceptions and acceptability of a remotely delivered physical activity intervention utilizing wearable sensors and personalized feedback messages.

Methods

In-person and virtual small group interviews were conducted engaging overweight/obese cancer survivors (n = 16, 94% female, 94% breast cancer survivors) in discussions resulting in 314 pages of transcribed data analyzed by multiple coders.

Results

All participants expressed needing to increase physical activity, identifying lack of motivation centering on survivorship experiences and symptom management as the most salient barrier. They indicated familiarity with activity trackers (i.e., Fitbit) and expressed interest in biosensors (i.e., continuous glucose monitors [CGMs]) as CGMs show biological metrics in real-time. Participants reported (1) personalized feedback messages can improve motivation and accountability; (2) CGM acceptability is high given survivors’ medical history; and (3) glucose data is a relevant health indicator and they appreciated integrated messages (between Fitbit and CGM) in demonstrating how behaviors immediately affect one's body.

Conclusions

This study supports the use of wearable biosensors and m-health interventions to promote physical activity in cancer survivors. Glucose-based biofeedback provides relevant and motivating information for cancer survivors regarding their daily activity levels by demonstrating the immediate effects of physical activity. Integrating biofeedback into physical activity interventions could be an effective behavioral change strategy to promote a healthy lifestyle in cancer survivors.

Motives for Physical Activity in Prostate Cancer Survivors: A Qualitative Exploration

Physical activity (PA) is beneficial for both the physical and psychological health of prostate cancer (PCa) survivors. This study identified and examined motives for PA in a cross-section of PCa survivors, including both men in remission and those receiving treatment in the form of androgen deprivation therapy (ADT). Sixteen PCa survivors from Auckland, New Zealand were individually interviewed. Data were analyzed using an inductive thematic approach. Both groups of men were motivated to engage in PA post-diagnosis to obtain and experience the physical, mental, and cognitive health-related benefits associated with regular PA engagement. Past history of PA was also identified as a motive for current PA for men in remission. These findings provide important insight into how PCa survivors perceive the benefits of PA as a part of their cancer survivorship. Healthcare practitioners, exercise physiologists, and cancer support organizations can use this information to further improve PCa survivors’ quality of life and overall cancer survivorship by better promoting PA to these individuals.

Effects of remotely-delivered physical activity education on exercise beliefs and intentions of active and nonactive cancer survivors and their partners

Physical activity (PA) is recommended for cancer survivors and their romantic partners yet cancer couples may be unaware of the benefits of PA specific to them. Exercise interventions targeting survivors and partners simultaneously may prove effective at increasing exercise knowledge, intentions, and outcomes. To examine the effects of a remotely-delivered cancer-specific exercise education video on cancer survivors’ and their partners’ exercise knowledge, beliefs, and intentions. Cancer survivors (N = 209) and their romantic partners (N = 155) completed an online survey with an embedded education video randomized to half the sample. Group differences (education vs. control) on study constructs among the whole sample and on a subset of the sample not meeting exercise guidelines [i.e., less than 150 min of moderate to vigorous physical activity (MVPA) per week; 50.5% survivors, 45.1% partners] were examined. Group differences on study constructs were also tested between survivors and partners meeting exercise guidelines or not. Survivors and partners in the education condition were more likely to correctly report the MVPA guidelines. The education increased survivors’ personal exercise importance, outcome expectations, and likelihood of joining an individual exercise program. Participants meeting guidelines were significantly different on multiple exercise beliefs compared to those who were not. Among those not meeting guidelines, the education increased survivors’ belief in the importance of exercising with their partner. A remotely-delivered exercise education video increased exercise knowledge and beliefs, which represents an important step in the development of couples’ exercise interventions for cancer survivors and their romantic partners.

The Acceptability of an Electronically Delivered Acceptance- and Mindfulness-Based Physical Activity Intervention for Survivors of Breast Cancer: One-Group Pretest-Posttest Design

Background

Survivors of breast cancer can face internal barriers to physical activity, such as uncertainty and frustration stemming from physical limitations, decreased physical functioning, fatigue, and pain. Interventions that draw from the principles of Acceptance and Commitment Therapy (ACT) may help survivors of breast cancer overcome some of the internal barriers associated with physical activity.

Objective

The primary aim of this study was to investigate the acceptability of an electronically delivered physical activity intervention for survivors of breast cancer, centered on ACT processes.

Methods

This study used a 1-group pretest-posttest design. We recruited 80 insufficiently active female survivors of breast cancer using a web-based recruitment strategy. The 8-week intervention consisted of weekly modules that featured didactic lessons and experiential exercises targeting key ACT processes in the context of physical activity promotion (namely, values, committed action, acceptance, defusion, and contacting the present moment). We determined intervention acceptability according to study retention (≥70%), adherence rates (≥75% of the participants completing ≥50% of the modules), and posttest survey scores reflecting the perceived ease of use, perceived usefulness, and interest and enjoyment of the intervention (≥5 on a 7-point Likert-type scale). We also evaluated changes in self-reported aerobic and muscle strengthening–physical activity, physical activity acceptance, physical activity regulation, and health-related outcomes.

Results

The retention rate (61/80, 76%), adherence rate (60/80, 75%), average perceived ease of use (6.17, SD 1.17), perceived usefulness (5.59, SD 1.40), and interest and enjoyment scores (5.43, SD 1.40) met the acceptability criteria. Participants increased their self-reported aerobic physical activity (Cohen d=1.04), muscle strengthening–physical activity (Cohen d=1.02), physical activity acceptance (cognitive acceptance: Cohen d=0.35; behavioral commitment: Cohen d=0.51), physical activity regulation (identified regulation: Cohen d=0.37; integrated regulation: Cohen d=0.66), increased their ability to participate in social roles and activities (Cohen d=0.18), and reported less fatigue (Cohen d=0.33) and sleep disturbance (Cohen d=0.53).

Conclusions

Electronically delivered acceptance- and mindfulness-based interventions may be useful for promoting physical activity in survivors of breast cancer. Further research is needed to refine these approaches and evaluate their effectiveness.

An app with brief behavioural support to promote physical activity after a cancer diagnosis (APPROACH): study protocol for a pilot randomised controlled trial

Background

There are multiple health benefits from participating in physical activity after a cancer diagnosis, but many people living with and beyond cancer (LWBC) are not meeting physical activity guidelines. App-based interventions offer a promising platform for intervention delivery. This trial aims to pilot a theory-driven, app-based intervention that promotes brisk walking among people living with and beyond cancer. The primary aim is to investigate the feasibility and acceptability of study procedures before conducting a larger randomised controlled trial (RCT).

Methods

This is an individually randomised, two-armed pilot RCT. Patients with localised or metastatic breast, prostate, or colorectal cancer, who are aged 16 years or over, will be recruited from a single hospital site in South Yorkshire in the UK. The intervention includes an app designed to encourage brisk walking (Active 10) supplemented with habit-based behavioural support in the form of two brief telephone/video calls, an information leaflet, and walking planners. The primary outcomes will be feasibility and acceptability of the study procedures. Demographic and medical characteristics will be collected at baseline, through self-report and hospital records. Secondary outcomes for the pilot (assessed at 0 and 3 months) will be accelerometer measured and self-reported physical activity, body mass index (BMI) and waist circumference, and patient-reported outcomes of quality of life, fatigue, sleep, anxiety, depression, self-efficacy, and habit strength for walking. Qualitative interviews will explore experiences of participating or reasons for declining to participate. Parameters for the intended primary outcome measure (accelerometer measured average daily minutes of brisk walking (≥ 100 steps/min)) will inform a sample size calculation for the future RCT and a preliminary economic evaluation will be conducted.

Discussion

This pilot study will inform the design of a larger RCT to investigate the efficacy and cost-effectiveness of this intervention in people LWBC.

Trial registration

ISRCTN registry, ISRCTN18063498. Registered 16 April 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01028-w.

'You're kind of left to your own devices': a qualitative focus group study of patients with breast, prostate or blood cancer at a hospital in the South West of England, exploring their engagement with exercise and physical activity during cancer treatment and in the months following standard care

OBJECTIVES

The aim of this study was to explore the experiences of patients with breast, prostate or blood cancer, regarding their (1) engagement with exercise and physical activity during treatment and in the months following standard care, and (2) the meanings attached to these lifestyle behaviours.

DESIGN

A qualitative study using focus groups. The groups were audio recorded, transcribed and analysed using Framework analysis.

SETTING

A hospital-based cancer treatment centre in the South-West of England.

PARTICIPANTS

Eighteen people who had either completed treatment or were currently on maintenance therapy for breast, prostate or blood cancer (non-Hodgkin lymphoma or Hodgkin lymphoma).

RESULTS

Participants reported treatment limiting their ability to engage in exercise and physical activity. However, participants were aware of the physiological, emotional and social benefits of exercise and expressed a desire to maintain a physically active lifestyle before, during and after treatment. They noted a lack of concrete guidance and appropriate exercise classes for people with cancer and felt poorly informed about the type, intensity, duration and frequency of exercise they should be undertaking. As such, participants reported making decisions on their own, relying on their intuition and listening to their bodies to gauge whether they were doing enough exercise (or not).

CONCLUSIONS

Participants were aware of the benefits of a physically active lifestyle during and following cancer treatment, but were not familiar with exercise and physical activity guidelines for people living with and beyond cancer. There is a need for healthcare professionals, academics and policy makers to determine how exercise and physical activity can be supported in clinical settings in realistic and meaningful ways accommodating individual patient circumstances.

Physical exercise habits, lifestyle behaviors, and motivation to change among men with prostate cancer: a cross-sectional study

PURPOSE

To describe the physical exercise (PE) habits, lifestyle, and motivation to change toward healthier behaviors in patients newly diagnosed with prostate cancer (PCa).

METHODS

A cross-sectional study was conducted in an Italian hospital setting. Men newly diagnosed with PCa were consecutively invited to participate in a structured interview that was conducted either in person or by telephone.

RESULTS

The mean age of the 40 participants was 70.5 ± 6.6 (range 50-84). Most participants (65%) reported they were physically active, but more than half of the sample did not reach the recommended PE level. However, 40% of participants would be interested in participating in an exercise program. Only 10% of participants were current smokers, but 90% drank alcohol, and 62.5% were overweight/obese. Almost all participants were not willing to change their habits.

CONCLUSIONS

A high proportion of Italian men are insufficiently active when diagnosed with PCa. Moreover, even when exposed to behavioral risk factors, they are not willing to change their lifestyle. Health-care professionals who deal with men newly diagnosed with PCa should take advantage of the teachable moment and apply strategies that support patients' motivation to exercise and adherence to healthier lifestyles.

TRIAL REGISTRATION

The study was prospectively registered in ClinicalTrial.gov NCT03982095 on June 11, 2019.

Predictors of cardiopulmonary fitness in cancer-affected and -unaffected women with a pathogenic germline variant in the genes BRCA1/2 (LIBRE-1)

Physical activity (PA) helps prevention and aftercare of sporadic breast cancer (BC), cardiopulmonary fitness (CPF) being an age-independent predictor of tumor-specific mortality. Therefore, we wanted to identify predictors of CPF (represented by peak oxygen uptake: VO_2peak) in BRCA1/2 mutation carriers whose risk of developing BC is high. We used cross-sectional data from 68 BRCA1/2 germline mutation carrying women participating in the randomized, prospective, controlled clinical study LIBRE-1. Assessments included cardiopulmonary exercise testing, medical and lifestyle history plus socioeconomic status. Additionally, the participants completed a psychological questionnaire regarding their attitude, subjective norms, perceived behavior control and intention towards PA. A multivariate logistic regression model was used to identify predictors for participants reaching their age- and sex-adjusted VO_2peak reference values. 22 participants (median age: 40 years, interquartile range (IQR) 33–46) were cancer-unaffected and 46 cancer-affected (median age: 44 years, IQR 35–50). The strongest predictor for reaching the reference VO_2peak value was attitude towards PA (Odds Ratio 3.0; 95% Confidence Interval 1.3–8.4; p = 0.021). None of the other predictors showed a significant association. A positive attitude towards PA seems to be associated with VO_2peak, which should be considered in developing therapeutic and preventive strategies.

Trial registrations: NCT02087592; DRKS00005736.

Patients' reflections on undergoing non-myeloablative allogeneic haematopoietic stem cell transplantation and participating in a multimodal interdisciplinary rehabilitation programme: A qualitative study

PURPOSE

To explore participants' experiences and perspectives on the relevance and meaning of participating in the multimodal interdisciplinary rehabilitation programme named 'HAPPY', and the programme's influence on their handling of everyday life during and after non-myeloablative allogeneic haematopoietic stem cell transplantation.

METHOD

A qualitative interview study using Thorne's interpretive description methodology. A semi-structured interview guide and the analysis were inspired by symbolic interactionism. From April to July 2020, individual interviews were conducted with 24 patients who had participated in HAPPY while undergoing non-myeloablative haematopoietic stem cell transplantation.

RESULTS

HAPPY contributed to the patients' knowledge building on the basis of three themes: Social Solidarity and Comparison, Processing Mind and Body, and Balancing Disease and Life. HAPPY supported the participants in maintaining their physical functioning and induced a perception of empowerment. Moreover, HAPPY supported patients in their efforts to familiarise themselves with their changed life conditions after the stem cell transplantation.

CONCLUSION

Our findings showed that participation in HAPPY empowered patients to manage and cope with the stresses of everyday life and restore balance in their lives whilst undergoing treatment and confronting their cancer diagnosis. The findings underline the importance of elements of peer support and continuous support and facilitation from the specialist team, and the possibility to rethink the use of online technology to support and ensure a balance between disease and life and to minimise hospital visits.

Study protocol for the investigation of the clinical effectiveness of a physical activity behaviour change intervention for individuals living with and beyond cancer

Most individuals living with and beyond cancer are not sufficiently active to achieve the health benefits associated with regular physical activity (PA). The purpose of this study was to describe the study protocol for a two-arm non-randomised comparison trial conducted within a community-based setting, which aimed to investigate the clinical effectiveness of a cancer-specific PA behaviour change (BC) intervention, namely MedEx IMPACT (IMprove Physical Activity after Cancer Treatment), compared to a general exercise rehabilitation programme, among survivors of cancer. Individuals who had completed active-cancer treatment who were referred to a community-based exercise rehabilitation programme were invited to participate in the trial. Participants in the control group (CG) attended twice-weekly supervised exercise classes for 12 weeks. Classes were delivered as part of a chronic illness exercise rehabilitation programme. Participants in the MedEx IMPACT intervention group (IG) also attended the twice-weekly supervised exercise classes for 12 weeks and received cancer-specific materials, namely an independent PA programme, 4 PA information sessions and a 1:1 exercise consultation. The primary outcome was PA levels measured by 6-day accelerometry and self-report PA. Secondary outcomes included cardiorespiratory fitness (CRF), quality of life (QoL) and sedentary behaviour. Outcomes were measured at baseline and months 3, 6 and 12. Few effective PA BC interventions for individuals living with and beyond cancer have been identified. The results of this study will have implications for the planning and provision of community-based exercise oncology rehabilitation programmes for individuals living with and beyond cancer.

Barriers and facilitators to exercise among adult cancer survivors in Singapore

PURPOSE

Exercise can help cancer survivors manage sequela, treatment side effects, improve overall quality of life, and is recommended for most. The purpose of this study was to investigate exercise behavior and factors influencing exercise engagement among cancer survivors at the National Cancer Centre, Singapore (NCCS).

METHODS

This cross-sectional study was inclusive of survivors of all cancer types and stages who were at least 21 years of age and had undergone chemotherapy at the NCCS. Surveys were utilized to assess survivor barriers and facilitators to exercise and to retrospectively assess physical activity and exercise behaviors at 4 cancer-related time periods (pre-diagnosis and post-diagnosis before, during, or after chemotherapy).

RESULTS

A total of 102 cancer survivors were enrolled; 60% were diagnosed with stage IV cancer. Predominant cancer types included lower gastrointestinal tract (25.5%) and breast cancer (21.6%). Prior to cancer diagnosis, 90.2% of participants reported aerobic activity satisfying NCCN guidelines. Significant reductions in reported exercise, and physical activity, were observed following cancer diagnosis that persisted during chemotherapy. Key exercise facilitators included the desire to remain healthy (86.3%) and to improve sleep and mental well-being (73.5%). Key barriers included side effects of treatment (52.0%). Only 46.1% of survivors reported receiving exercise guidance from healthcare professionals following diagnosis.

CONCLUSION

Overall, even among this notably active cohort of Singaporean survivors, opportunities for increased exercise engagement throughout the survivorship continuum remain. Increased education regarding the benefits of exercise to survivors as well as guidance regarding exercise modalities including resistance training is greatly needed as well.

Implementation barriers to integrating exercise as medicine in oncology: an ecological scoping review

Purpose

While calls have been made for exercise to become standard practice in oncology, barriers to implementation in real-world settings are not well described. This systematic scoping review aimed to comprehensively describe barriers impeding integration of exercise into routine oncology care within healthcare systems.

Methods

A systematic literature search was conducted across six electronic databases (since 2010) to identify barriers to implementing exercise into real-world settings. An ecological framework was used to classify barriers according to their respective level within the healthcare system.

Results

A total of 1,376 results were retrieved; 50 articles describing implementation barriers in real-world exercise oncology settings were reviewed. Two hundred and forty-three barriers were identified across all levels of the healthcare system. Nearly 40% of barriers existed at the organizational level (n = 93). Lack of structures to support exercise integration and absence of staff/resources to facilitate its delivery were the most common issues reported. Despite the frequency of barriers at the organizational level, organizational stakeholders were largely absent from the research.

Conclusions

Implementing exercise into routine cancer care is hindered by a web of interrelated barriers across all levels of the healthcare system. Organizational barriers are central to most issues. Future work should take an interdisciplinary approach to explore best practices for overcoming implementation barriers, with organizations as a central focus.

Implications for Cancer Survivors

This blueprint of implementation barriers highlights critical issues that need to be overcome to ensure people with cancer have access to the therapeutic benefits of exercise during treatment and beyond.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01080-0.

Exploring cancer survivors' experiences in a group-based walking program before and during the COVID-19 pandemic: a qualitative study

Purpose

Physical activity (PA) can help reduce side effects related to cancer whilst promoting quality of life. This qualitative study explored cancer survivors’ experiences in an 8-week group-based walking program with behavioural support that was delivered within the community to highlight factors central to successful adoption and sustainability of such programs.

Methods

Eleven cancer survivors who took part in the program before (n = 7) or during (n = 4) the COVID-19 pandemic were interviewed and asked to discuss their PA behaviour, motivation to join and complete the program, and experienced benefits and barriers, as well as offer feedback that could be incorporated into future programs. Interview transcripts were thematically analysed using a hybrid deductive-inductive approach.

Results

Participants’ experiences were summarised into six themes: (1) PA behaviour and motivation were enhanced, (2) seeking accountability to take steps for better health, (3) mutual support encourages in-group bonding, (4) placing value on building PA confidence, (5) the impact of the COVID-19 pandemic and (6) recommendations for future programs. By receiving social and behavioural support, and thus experiencing increased PA confidence, participants felt the program supported their PA behaviour. However, key differences were evident for participants attending the program during the pandemic.

Conclusions

Exploring strategies that foster a communal focus amongst participants within community-based walking programs may be beneficial. Moreover, findings underscore the value of offering PA programming (walking or otherwise) with behavioural support during a pandemic with appropriate safety measures, though social relationships may not be fully fostered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06529-7.

Factors Influencing Physical Activity in Cancer Patients During Oncological Treatments: A Qualitative Study

Introduction:

Although the literature supports the importance of physical activity in the oncological context, in Italy a large number of patients are not sufficiently active.

Methods:

The present study aimed to explore factors influencing an active lifestyle in cancer patients during oncological treatments. Semi-structured focus groups, including 18 patients with different cancer types, were conducted at the Oncology Unit in the University Hospital Trust of Verona (Italy). The interviews were audio-recorded, transcribed verbatim, and analyzed with content analysis.

Results:

According to the Health Belief Model, transcripts were categorized into the following themes: benefits, barriers, and cues to action. Patients reported a series of physical, physiological, and psychological benefits deriving from an active lifestyle. The main barriers hampering the physical activity participation were represented by treatment-related side effects, advanced disease, and some medical procedures, for example, ileostomy. Several strategies that can trigger patients to exercise were identified. Medical advice, social support from family and friends, features such as enjoyment, setting goals, and owning an animal can motivate patients to perform physical activity. At the same time, an individualized program based on patients’ characteristics, an available physical activity specialist to consult, more detailed information regarding physical activity in the oncological setting, and having accessible structures were found important facilitators to implementing active behavior.

Conclusions:

Overall, patients have a positive view regarding physical activity, and a variety of obstacles and cues to action were recognized. Considering this information may help to improve adherence to a physical activity program over time, consequently increasing the expected benefits.

Acceptance- and mindfulness-based techniques for physical activity promotion in breast cancer survivors: a qualitative study

Purpose

The purpose of this study was to develop and characterize the relevance and potential utility of an electronically delivered acceptance- and mindfulness-based approaches to physical activity promotion for insufficiently active breast cancer survivors.

Methods

The acceptance- and mindfulness-based physical activity intervention was delivered to participants electronically over the course of 4–8 weeks. It consisted of didactic videos, experiential exercises, and workbook-type activities that targeted principles from acceptance and commitment therapy (ACT). We conducted semi-structured, in-depth interviews with participants after they completed the intervention. Three coders conducted qualitative data analysis on interview transcripts to identify overarching themes and subthemes.

Results

We recruited 30 participants. Of those, 16 engaged in an individual interview. The mean age of the sample was 58.4 years (SD = 13.8). The sample was relatively well educated (50.0% college graduates) and mostly overweight or obese (58.8%). We identified two overarching themes from interviews. They were centered on (1) internal and external barriers to physical activity adherence and (2) the utility of targeting core ACT processes (acceptance and defusion, mindfulness, and values clarification) for physical activity promotion.

Conclusion

Intervention content was perceived to be acceptable, relevant, and to fulfill important needs related to healthy living. Findings suggest that this approach to physical activity promotion can be delivered effectively online. Electronically delivered acceptance- and mindfulness-based approaches hold promise for helping insufficiently active breast cancer survivors increase physical activity.

Physical Activity During and After Haematological Cancer Treatment: A Cross-Sectional Survey of Haematology Healthcare Professionals in the United Kingdom

PURPOSE

Health professionals' (HPs) knowledge of recommended guidelines for physical activity (PA) is thought to influence the advice they provide to their patients. Little is known about the knowledge or provision of PA advice by HPs working with haematological cancer patients. This study examined awareness of PA guidance, beliefs and practices in provision of advice given by UK HPs working with haematological cancer patients.

METHODS

Online survey including questions on awareness of PA guidance, levels of agreement/disagreement with statements related to PA in haematological cancer and reported provision of advice in practice. Open text responses sought detail regarding guidance knowledge and exampled advice given by respondents. Predictors of familiarity of guidance and provision of advice were examined.

RESULTS

Complete responses were received from 156 professionals, mostly nurses, allied HPs and doctors. Many (31%) reported knowing relevant guidance and nearly half (48.6%) reported routinely giving PA advice. Nurses and allied AHPs give advice to more patients than doctors and knowledge of guidelines among doctors was poor.

CONCLUSION

Beliefs of haematology professionals regarding the role of PA during and after treatment for haematological cancer were generally positive. Those reporting familiarity with guidance were more likely to give advice. Misalignment exists between guidelines and advice given by professionals to their patients. Increasing knowledge of guidelines among HPs, including nurses, may lead to increased provision of PA advice and promotion of PA to more of their patients. HPs education in haematology on PA guidance tailored to professional group is needed.

mHealth Interventions to Address Physical Activity and Sedentary Behavior in Cancer Survivors: A Systematic Review

This review aimed to identify, evaluate, and synthesize the scientific literature on mobile health (mHealth) interventions to promote physical activity (PA) or reduce sedentary behavior (SB) in cancer survivors. We searched six databases from 2000 to 13 April 2020 for controlled and non-controlled trials published in any language. We conducted best evidence syntheses on controlled trials to assess the strength of the evidence. All 31 interventions included in this review measured PA outcomes, with 10 of them also evaluating SB outcomes. Most study participants were adults/older adults with various cancer types. The majority (n = 25) of studies implemented multicomponent interventions, with activity trackers being the most commonly used mHealth technology. There is strong evidence for mHealth interventions, including personal contact components, in increasing moderate-to-vigorous intensity PA among cancer survivors. However, there is inconclusive evidence to support mHealth interventions in increasing total activity and step counts. There is inconclusive evidence on SB potentially due to the limited number of studies. mHealth interventions that include personal contact components are likely more effective in increasing PA than mHealth interventions without such components. Future research should address social factors in mHealth interventions for PA and SB in cancer survivors.

Factors influencing physical activity participation among people living with or beyond cancer: a systematic scoping review

BACKGROUND

It has been posited that physical activity (PA) has the potential to improve health outcomes and the health-related quality of life of people living with or beyond cancer. Despite the well-documented health benefits of PA, there is a low level of PA among cancer patients. A systematic scoping review was conducted to investigate attitudes, perceptions, preferences and barriers vs. facilitators to cancer patients' PA participation.

METHODS

A systematic search was performed across four automated databases (PubMed, Embase, PsycINFO and Medline) in keeping with the PRISMA guideline. All cancer types were included, and any age/gender groups were eligible. Both qualitative and quantitative studies were included. The Health Belief Model provided a conceptual framework for the conduct of the scoping review as well as guiding thinking to inform evidence-based interventions.

RESULTS

Ninety-eight articles were included in this review. Nearly half of the studies focused on mixed cancer sites; breast cancer was the most commonly examined cancer type (19%). Post-treatment was the most commonly investigated stage (33%), followed by studies of mixed stages of the cancer trajectory (27%), the acute treatment stage (23%) and pre-treatment stage (1%). Patient treatment stage was not reported in 16% of studies. Cancer patients reported positive attitudes to PA and recognized its benefits for health and wellbeing. Cancer-related side effects (e.g. fatigue) were a leading physiological barrier to PA participation, whereas effective symptom management techniques/tools acted as a powerful facilitator. Psychosocial barriers included low motivation and kinesiophobia, and perceived health benefits and social support/guidance by healthcare providers were significant facilitators. Inaccessible fitness facilities hindered cancer patients' PA engagement though the availability of tailored amenities appeared to be a strong facilitator. PA preferences varied in terms of type, place, time, company and source of information and pointed to the need for individualized PA programs.

CONCLUSIONS

There is a need for further research to identify barriers and facilitators to PA that are faced by patients with particular cancer types. Recommended PA promoting-strategies involve including exercise science professionals in healthcare teams and ensuring that fitness facilities are accessible.

Remote interventions to improve exercise behaviour in sedentary people living with and beyond cancer: a systematic review and meta-analysis

BACKGROUND

The COVID-19 pandemic has forced many cancer services to consider a transition to a remote format of delivery that is largely untested. Accordingly, we sought to perform a systematic review of the effects of remotely delivered interventions to improve exercise behaviour in sedentary adults living with and beyond cancer.

METHODS

Eligible studies were randomised controlled trials comparing a remotely delivered exercise intervention to a usual care comparison in sedentary people over 18 years old with a primary cancer diagnosis. Nine electronic databases were searched from inception to November 2020.

RESULTS

The review included three trials, totalling 186 participants. Two of the included trials incorporated prescriptions that meet current aerobic exercise recommendations, one of which also meets the guidelines for resistance exercise. No trials reported an intervention adherence of 75% or more for a set prescription that meets current exercise guidelines.

CONCLUSION

There is little evidence suggesting that remote exercise interventions promote exercise behaviours or improve physical function in sedentary adults living with and beyond cancer. The development and evaluation of novel remote exercise interventions is needed to establish their usefulness for clinical practice. Given the social response to the COVID-19 pandemic, further research in this area is urgently needed.

Systematic Review of Behaviour Change Theories Implementation in Dietary Interventions for People Who Have Survived Cancer

Background: An increasing number of dietary interventions for cancer survivors have been based on the behaviour change theory framework. The purpose of this study is to review the use and implementation of behaviour change theories in dietary interventions for people after cancer and assess their effects on the reported outcomes. Methods: The search strategy from a Cochrane review on dietary interventions for cancer survivors was expanded to incorporate an additional criterion on the use of behaviour change theory and updated to September 2020. Randomised controlled trials (RCT) testing a dietary intervention compared to the control were included. Standard Cochrane methodological procedures were used. Results: Nineteen RCTs, with 6261 participants (age range 44.6 to 73.1 years), were included in the review. The Social Cognitive Theory was the most frequently used theory (15 studies, 79%). Studies included between 4 to 17 behaviour change techniques. Due to limited information on the mediators of intervention and large heterogeneity between studies, no meta-analyses was conducted to assess which theoretical components of the interventions are effective. Conclusions: Whilst researchers have incorporated behaviour change theories into dietary interventions for cancer survivors, due to inconsistencies in design, evaluation and reporting, the effect of theories on survivors’ outcomes remains unclear.

Designing an exercise intervention for adult survivors of childhood cancers

BACKGROUND

This study examined current physical activity levels and preferences for exercise settings and activities among adult survivors of childhood cancers as a strategy to inform the feasibility and design of such programs.

METHODS

A mixed-methods design was used to investigate current activity levels as well as barriers to and preferences for physical activity among 20 adult survivors of pediatric cancer.

RESULTS

One-half of participants reported engaging in regular physical activity, although the frequency, intensity, and duration varied. Overall, 17 of the 20 participants (85%) stated they would be interested in participating in a structured exercise intervention, and they expressed a strong interest in walking (76%), bicycling (53%), and weight training (53%). Common barriers to participation in a potential structured exercise program were insufficient time, current health issues, and program location/distance. Nearly all participants agreed that information on nutrition and diet should be included as part of an exercise intervention.

CONCLUSIONS

These findings will help inform the design and implementation of future exercise programs to enhance physical activity among this high-risk group of cancer survivors.

Tumorbedingte Fatigue - Prozessevaluation eines Seminars der Universitätsmedizin Greifswald

Cancer-related fatigue - Process evaluation of a seminar of the University Medicine Greifswald Abstract. Background: Fatigue is the most common and stressful symptom in cancer patients and their relatives. The patient information center (PIZ) of the University Medicine Greifswald enables patients to learn how to deal with fatigue and to understand their disease. The fatigue seminar is well accepted by seminar participants, but it is rarely taken up by patients. Aim: The primary objective of this observational study was to find out how well-known this seminar is, whether it is recommended to patients and what the reasons for missing referrals are.

METHODS

Medical and nursing staff of all 13 wards of the Oncology Centre was surveyed by means of a self-developed questionnaire. The questions were analyzed on a single item level. Descriptive statistics and measures of correlation were determined.

RESULTS

The fatigue seminar of the PIZ is hardly known to the n = 115 respondents and / or is not always recommended to those affected. Where the PIZ has been present in the past, the knowledge about fatigue is higher and the seminar is better known. Screening instruments are hardly used for diagnostics.

CONCLUSIONS

The fatigue seminar needs to be promoted in a better way. In order to increase its popularity, it should be presented both to the psychological staff and on the wards. The systematic inclusion of screening instruments in the treatment path of cancer patients and the inclusion of the fatigue seminar in the range of treatment for patients with distressing fatigue symptoms should be discussed.

Gamified Text Messaging Contingent on Device-Measured Steps: Randomized Feasibility Study of a Physical Activity Intervention for Cancer Survivors

BACKGROUND

Physical activity can confer diverse benefits on cancer survivors. Unfortunately, many cancer survivors are not sufficiently active. The efficacy of physical activity interventions for this population may be increased by grounding them in Self-Determination Theory (SDT). Combining game design elements with wearable technologies may be a useful and scalable approach to targeting SDT constructs to promote cancer survivors' physical activity.

OBJECTIVE

The primary aim of this study is to evaluate the feasibility and acceptability of Steps2Health, a physical activity intervention for cancer survivors. It also aims to investigate the effects of the intervention on motivation, physical activity, and step count.

METHODS

We randomized 78 insufficiently active cancer survivors to an experimental or comparison group. All participants received a physical activity tracker. The experimental group participants also received a set sequence of multimedia messaging service messages that were triggered in real time by meeting predetermined cumulative step count totals. Messages presented information about a virtual journey and included photographs and vivid descriptions of locations to increase autonomous motivation. Additional messages targeted perceptions of relatedness (eg, role modeling) and competence (eg, facilitating mastery experiences). We administered pre- and postintervention surveys and conducted 15 individual interviews to evaluate the intervention. We performed directed content analysis of qualitative data and conducted mixed effects linear modeling to investigate participants' changes in motivation, self-reported physical activity, and device-measured step counts.

RESULTS

There was minimal loss to follow-up (3/78, 4%), the device wear rate was high (2548/3044, 83.71% of days), and technical problems with messaging based on real-time step counts were limited. Our qualitative data analysis revealed 3 overarching themes: accessibility, autonomous motivation, and relatedness. Participants successfully navigated the technological aspects and game design elements of the intervention. Participants found messages targeting autonomous motivation and competence or self-efficacy to be enjoyable and compelling, but one feasibility criterion for participant engagement (response rate to text messages) was not met. Messages targeting relatedness were less highly rated than the messages targeting autonomous motivation and competence or self-efficacy. During the intervention, both groups increased their motivation for physical activity (B=0.16; 95% CI 0.01 to 0.30; P=.04; d=0.49), and assignment to the experimental group was associated with increased self-reported leisure activity score (B=10.78; 95% CI 3.54 to 18.02; P=.005; d=0.64). The experimental group had greater increases in daily step counts over time (B=322.08; 95% CI 54.01 to 590.15; P=.02; d=0.28).

CONCLUSIONS

This study supports the feasibility of using real-time game design elements to target SDT constructs and increase cancer survivors' physical activity. Overall, our findings support the acceptability of the Steps2Health intervention, but fostering active participant engagement and targeting relatedness may present additional challenges. Steps2Health may help cancer survivors increase their physical activity levels.

Dietary behaviours, physical activity and quality of life among childhood cancer survivors in Mainland China: A cross-sectional study

OBJECTIVE

To examine the dietary behaviours, physical activity (PA) and quality of life (QoL) of childhood cancer survivors (CCS) in Mainland China and explore the relationships between these behaviours and QoL.

METHODS

This cross-sectional study recruited 181 CCS from three Grade-A tertiary hospitals in Guangzhou. Survivors completed questionnaires assessing their dietary behaviours, PA and QoL.

RESULTS

Only 2.2%, 7.7% and 2.2% of CCS reported frequent soft drinks, sugar and fast food intake, which were lower compared to CCS in Western studies. Most survivors (72.9%) failed to drink milk daily, and many (54.7%) were picky eating. Sixty percent of CCS reported less moderate-to-vigorous physical activity (MVPA) time than 60 min/day recommended by WHO. Picky eating was significantly associated with lower overall (p < 0.001), physical (p < 0.001) and psychosocial (p < 0.001) QoL. MVPA was significantly positively associated with overall (p < 0.05) and psychosocial (p < 0.01) QoL.

CONCLUSIONS

Chinese CCS engaged better dietary behaviours of less soft drinks, sugar and fast food consumption, but many were picky eaters and did not meet milk intake and PA recommendations. Early behavioural interventions aimed at increasing the dietary diversity and MVPA level of this population should be taken to improve their QoL.

Social support and physical activity for cancer survivors: a qualitative review and meta-study

PURPOSE

Physical activity (PA) is important for well-being and coping among cancer survivors. Social support (SS) encourages adoption and maintenance of PA behavior, and PA contexts can provide opportunities for obtaining support for coping with cancer. The qualitative literature examining cancer survivors' experience with SS in and for PA could inform understanding of behaviors experienced as supportive. The purpose of this meta-study was to synthesize the research on adult cancer survivors' experiences with SS related to PA.

METHODS

Following meta-study guidelines, we searched nine databases and retrieved 39 articles describing intervention and observation studies, and extracted, analyzed, and synthesized information addressing SS and PA in cancer survivors.

RESULTS

Results emphasized ways that PA contexts facilitate relationships, which are a foundation for obtaining supportive behaviors that enable PA (e.g., providing encouragement and accountability) and assist with coping with cancer (e.g., understanding and talking about cancer). Some themes identified were unique to studies with female breast cancer, advanced cancer, interventions or programs, and that used interviews versus focus groups.

CONCLUSIONS

Understanding supportive behaviors could improve PA and coping with cancer in interventions. Future research should focus on identifying supportive behaviors, incorporating theory and methods to address the development of supportive relationships, and recruiting more diverse samples of participants in terms of gender, race/ethnicity, and cancer type.

IMPLICATIONS FOR CANCER SURVIVORS

PA can provide opportunities for positive social connections ranging from loose to close social ties, and this research identifies several behaviors in the PA context that may be supportive of PA behavior (e.g., providing actionable information), and coping with cancer (e.g., opportunities but low obligation to talk about cancer).

Sedentary behavior among breast cancer survivors: a longitudinal study using ecological momentary assessments

PURPOSE

Sedentary behavior (SB) or any waking behavior ≤ 1.5 METs is associated with an increase in body weight and fatigue and poor quality of life among cancer survivors. The purpose of this study was to explore longitudinal trends in SB using accelerometers and associated variables via ecological momentary assessments (EMA) among breast cancer survivors.

METHODS

Breast cancer survivors (within 5 years post-diagnosis) were recruited for a 12-month observational study. Participants were asked to download an EMA application to their smartphones to receive prompts for 7 days and to concurrently wear an Actigraph accelerometer. Participants responded to 35 prompts during each 7-day assessment period at baseline, and at 3, 6, 9, and 12 months. Within each prompt, participants were asked questions about their current level of affect, sadness, anxiety, stress, worry and fatigue, and cancer-related symptoms (e.g., neuropathy).

RESULTS

Twenty-two survivors (mean age = 51.5 years) were recruited and 20 participants completed the study. Mean baseline SB averaged 76.7 h/week. Univariate longitudinal models suggested higher levels of sadness, anxiety, stress, worry, and fatigue were associated with more SB while more positive affect was associated with less SB. Additionally, non-leisure context (work) was associated with more SB. Autoregressive models indicated cross-lagged effects of affective valence, fatigue, and SB.

CONCLUSIONS

More negative affective valence and higher fatigue were associated with more SB. Reducing negative affect valence and offering non-sedentary approaches to manage fatigue may help reduce SB.

IMPLICATIONS FOR CANCER SURVIVORS

Specific interventions are needed to reduce SB among cancer survivors-particularly those that target negative affect valence and fatigue.

Physical Activity and Cancer Care in the Atlantic Canadian Provinces: an Examination of Provider Beliefs, Practices, Resources, Barriers, and Enablers

Despite the well-established benefits of physical activity for cancer survivors, the vast majority of survivors are not sufficiently active to reap these benefits. While cancer-specific physical activity guidelines exist, it remains unclear whether there are sufficient resources to support these recommendations. The purpose of this qualitative study was to describe the available cancer-specific physical activity programs for cancer survivors in Atlantic Canada and explore barriers and enablers to program implementation. Interviews were conducted with a purposefully selected sample of oncology healthcare professionals, administrators, and cancer-specific physical activity program leaders to examine the attitudes and practices of key stakeholders with respect to physical activity and cancer-specific programming. Thirty participants, including 7 oncologists, 7 nurses, 6 allied healthcare professionals, 5 administrators, and 5 program leaders, completed an interview. Three over-arching themes emerged, including (1) knowledge, attitudes and need for physical activity; (2) implementation barriers; and (3) implementation enablers. The results of this study suggest that cancer survivors in Atlantic Canada may require additional resources and support with respect to physical activity throughout their cancer care journey.

The adapted Zelen was a feasible design to trial exercise in myeloma survivors

OBJECTIVES

We used a method rarely seen in cancer behavioral trials to explore methods of overcoming difficulties often seen in randomized controlled trials. We report our experiences of the adapted Zelen design, so that other researchers can consider this approach for behavioral trials.

STUDY DESIGN AND SETTING

The adapted Zelen design was used to explore the effects of exercise on multiple myeloma patients fatigue, quality of life, and physical outcomes. All participants consented to an observational cohort study of lifestyle factors but were unaware of subsequent randomization to remain in cohort only group or be offered an exercise intervention requiring second consent.

RESULTS

There was lower than expected uptake to the exercise offered group (57%), so the length of recruitment increased from 24 to 29 months to ensure power was reached. At enrollment, patients were unaware of the potential increased commitment, and as a result, 62% of participants allocated to the intervention declined because of the extra time/travel commitment required. This emulates clinical settings and suggests improvements in intervention delivery are required. Our findings suggest that the adapted Zelen design may be useful in limiting dropout of controls due to dissatisfaction from group allocation, or contamination of control arm.

CONCLUSION

Future use of this design warrants careful consideration of the study resources and recruitment time frames required but holds potential value in reducing contamination, control group dissatisfaction, and resulting dropout. Adapted Zelen design reduces selection bias and therefore gives clinicians a better understanding of acceptability in clinical settings. Future studies should evaluate control group experiences of the design and formally record contamination throughout the study to confirm its acceptability.

Putting Exercise Into Oncology Practice: State-of-the-Science, Innovation, and Future Directions

Physical activity provides numerous health benefits for cancer survivors. This review provides a summary of the evidence supporting the efficacy of physical activity to improve patient-reported and physiological outcomes during and after cancer therapy, discusses observational studies that have reported associations of physical activity with cancer outcomes and prognosis, summarizes ongoing phase III randomized trials of physical activity with clinical disease endpoints in cancer survivors, describes randomized trials of physical activity that have examined biomarkers hypothesized to relate to cancer outcomes and prognosis, reviews current guidelines for physical activity promotion among cancer survivors, and provides recommendations for novel strategies to disseminate and implement this evidence into clinical oncology practice to optimize patient outcomes.

An integrated model of exercise support for people affected by cancer: consensus through scoping

INTRODUCTION

Exercise support for people with cancer is a national priority. The purpose of this study was to identify the success factors necessary to create a model of exercise support for people affected by cancer in a large city in the north of England.

METHOD

Two groups of participants were recruited; people affected by cancer (n = 26) and professional stakeholders (n = 14) contributing to either focus groups or semi-structured interviews. Data were analysed using framework analysis.

RESULTS

Results from this study suggest that the promotion of exercise is not a priority in routine cancer care. Patients identified a lack of support and difficulty attaining information as a barrier to becoming active, emphasising a gulf between the patients' needs and the health professionals' priorities. People affected by cancer and professionals agreed that exercise was beneficial to cancer patients both during and after treatment. For an exercise pathway to be successful, key factors were identified including accessibility; tailored support; social interaction; affordability; competence of exercise delivery staff.

CONCLUSIONS

There was consensus on the importance of exercise and critical factors required to develop a sustainable, accessible and effective service. Evidence to inform the development of an exercise pathway for people affected by cancer is provided.Implications for rehabilitationExercise should be an included component of a cancer treatment plan, discussed and initiated from diagnosis.Health professionals have a responsibility to provide clear, consistent evidence-based advice on exercise.Exercise professionals must be appropriately trained in cancer rehabilitation according to National Institute for Health and care Excellence (2014).Individual assessments of exercise needs, preferences and cancer limitations will result in a bespoke plan of recommendations and support.The option of group activities has the advantage of increased social interaction, peer support and shared experiences.Available exercise/physical activity services should be accessible and affordable but may involve a modest contribution.

Health beliefs and engagement in moderate-to-vigorous-intensity physical activity among cancer survivors: a cross-sectional study

PURPOSE

Moderate-to-vigorous-intensity physical activity (PA) can alleviate many adverse side effects and symptoms caused by cancer treatments; yet, most cancer survivors are insufficiently active. Evidence shows that theory-based PA behavior change interventions are more effective than non-theory-based interventions; thus, it is necessary to ascertain modifiable theoretical factors associated with moderate-to-vigorous-intensity PA among cancer survivors. Drawing on the health belief model (HBM), the associations between moderate-to-vigorous-intensity PA and (1) perceived susceptibility to cancer recurrence and health problems, (2) perceived severity of cancer recurrence and health problems, (3) perceived benefits of PA for reducing risk of cancer recurrence and health problems, (4) perceived barriers to PA, and (5) PA barrier self-efficacy among cancer survivors were examined.

METHODS

A total of 123 adult cancer survivors (M_age = 50.1 ± 15.5 years; 82.9% female) completed an online self-report survey assessing sociodemographic and medical characteristics, moderate-to-vigorous-intensity PA, and the HBM constructs. Data were analyzed descriptively and using hierarchical linear regression analysis.

RESULTS

After adjusting for age, sex, body mass index, time since cancer diagnosis, and treatments received, the HBM constructs collectively explained 29% of the variance in moderate-to-vigorous-intensity PA. Perceived benefits of PA (β = .20, 95% CI [1.81, 11.67], p = .007) and PA barrier self-efficacy (β = .42, 95% CI [0.26, 0.53], p < .001) were significantly associated with moderate-to-vigorous-intensity PA.

CONCLUSION

Raising awareness of the benefits of PA for reducing risk of cancer recurrence and health problems and strengthening self-efficacy to overcome PA barriers may help to promote cancer survivors' attainment of moderate-to-vigorous-intensity PA guidelines.

Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care

Background: Lifestyle medicine interventions have the potential to improve symptom management, daily function, and quality of life (QOL) in patients with advanced or terminal disease receiving palliative or hospice care. The goal of this review is to summarize the current state of the literature on this subject. Methods: The authors used a broad search strategy to identify relevant studies, reviews, and expert opinions, followed by narrative summary of available information. Results: Four main categories of lifestyle interventions feature prominently in the palliative care literature: exercise, nutrition, stress management, and substance use. High-quality studies in this vulnerable population are relatively sparse. Some interventions show promise. However, most show mixed results or inadequate evidence. For some interventions, risks in this generally frail population outweigh the benefits. Clinical decision making involves balancing research findings, including the risks and benefits of interventions, with a clear understanding of patients' prognosis, goals of care, and current physical, emotional, and spiritual state. Achieving optimum QOL, safety, and ethical care are emphasized. Conclusions: The use of lifestyle interventions in patients receiving palliative or hospice care is a complex undertaking, requiring tailoring recommendations to individual patients. There is potential for considerable benefits; however, more research is needed.