Implementing exercise in cancer care: study protocol to evaluate a community-based exercise program for people with cancer

Predicting Quality of Life in Women with Breast Cancer Who Engage in Physical Exercise: The Role of Psychological Variables

In this study, we aimed to conduct a descriptive analysis of the primary physiological and psychological factors influencing the quality of life in women with breast cancer who engage in physical exercise. The study examined the key psychological variables predicting patients' quality of life, perceived support from family and friends, and the perception of physical condition. The sample consisted of 46 women from Cáceres (Spain) aged between 30 and 75 years undergoing breast cancer treatment. The Functional Evaluation Scale in Cancer Therapy (FACT-B+4) was used to measure quality of life; the Basic Psychological Needs Satisfaction Scale was used to measure autonomy, competence, and social relationships; the Behavior Regulation Questionnaire in Exercise (BREQ-3) was used to measure the types of self-determined motivation for sports participation; the General Evaluation of Self-Esteem Scale was used to measure self-esteem; the International Fitness Scale (IFIS) was used to measure perceived physical condition; and the Perceived Autonomy Support Scale for Exercise Settings (PASSES) was used to measure the perceived autonomy support from family and friends. A multiple regression analysis revealed that perceived physical condition and self-esteem were significant positive predictors of a variance in quality of life, while intrinsic motivation did not significantly predict it. The findings underscore the importance of promoting autonomous motivation in patients to enhance their physical and psychological well-being through physical activity.

Association between PhA and Physical Performance Variables in Cancer Patients

Maintaining the physical performance of cancer patients is increasingly considered due to the growing number of cancer patients and the aggressiveness of the treatments. For this reason, bioimpedance is now being used to record patients' body composition by obtaining the phase angle (PhA). Although there is a direct relationship between PhA, age, sex and disease prognosis, it has not been measured as an analysis of physical performance in oncology patients and is a valid tool in the follow-up of cancer patients. For this purpose, 311 patients were evaluated, and both bioelectrical impedance analysis (BIA) and physical performance measurements were performed. The modification of the results concerning PhA was found to be highly relational, as a variation in one of the variables affected the other. It was concluded that each degree increase in PhA modified -22.57 s [-27.58; -17.53] in 400-m walking test (400 mWT); 13.25 kg [10.13; 16.35] in upper-body strength (UBS); 6.3 [4.95; 7.65] in lower-body strength (LBS); 1.55 mL/kg/min [0.98; 2.12] in VO2peak; 6.53 Watts [3.83; 9.20] in ventilatory threshold 1 (VT1); 10.36 Watts [7.02; 13.64] in ventilatory threshold 2 (VT2). It was also noted that age was a factor that affected the relationship between PhA and 400 mWT; the older the age, the higher the relationship. PhA data has been shown to be highly correlated with physical performance. This is of great importance in clinical practice because a cancer patient's physical performance levels can be assessed during treatment.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Innovation

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICAL IMPLICATIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24835.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

Exercise interventions for people diagnosed with cancer: a systematic review of implementation outcomes

PURPOSE

Exercise is efficacious for people living after a cancer diagnosis. However, implementation of exercise interventions in real-world settings is challenging. Implementation outcomes are defined as 'the effects of deliberate and purposive actions to implement new treatments, practices, and services'. Measuring implementation outcomes is a practical way of evaluating implementation success. This systematic review explores the implementation outcomes of exercise interventions evaluated under real-world conditions for cancer care.

METHODS

Using PRISMA guidelines, an electronic database search of Medline, PsycInfo, CINAHL, Web of Science, SportsDiscus, Scopus and Cochrane Central Registry of Controlled Trials was conducted for studies published between January 2000 and February 2020. The Moving through Cancer registry was hand searched. The Implementation Outcomes Framework guided data extraction. Inclusion criteria were adult populations with a cancer diagnosis. Efficacy studies were excluded.

RESULTS

Thirty-seven articles that described 31 unique programs met the inclusion criteria. Implementation outcomes commonly evaluated were feasibility (unique programs n = 17, 54.8%) and adoption (unique programs n = 14, 45.2%). Interventions were typically delivered in the community (unique programs n = 17, 58.6%), in groups (unique programs n = 14, 48.3%) and supervised by a qualified health professional (unique programs n = 14, 48.3%). Implementation outcomes infrequently evaluated were penetration (unique programs n = 1, 3.2%) and sustainability (unique programs n = 1, 3.2%).

CONCLUSIONS

Exercise studies need to measure and evaluate implementation outcomes under real-world conditions. Robust measurement and reporting of implementation outcomes can help to identify what strategies are essential for successful implementation of exercise interventions.

IMPLICATIONS FOR CANCER SURVIVORS

Understanding how exercise interventions can be successful implemented is important so that people living after a cancer diagnosis can derive the benefits of exercise.

Evaluating implementation and pragmatism of cancer-specific exercise programs: a scoping review

PURPOSE

Studies in exercise oncology are increasingly evaluating the implementation of cancer-specific exercise programming in real-world settings. Evaluating current implementation efforts and identifying current research gaps may inform future implementation. This scoping review explores studies implementing cancer-specific exercise programs to determine their pragmatic characteristics and evaluate potential for translation into practice.

METHODS

A systematic literature search was conducted using five databases (up to July 2020) to identify implementation studies that used qualitative or quantitative methods. Program pragmatism was evaluated using the PRECIS/RE-AIM tool.

RESULTS

Fourteen articles were included for review. While programs were moderately pragmatic (average: 3.4; range: 2.8-4.2), variability was observed between scoring domains. Programs scored higher (more pragmatic) in domains typical for effectiveness studies, including participant eligibility, follow-up intensity, primary trial outcome, and analysis of primary outcome. In contrast, programs scored lower (less pragmatic) in domains aligned with implementation science, including intervention flexibility, adoption, implementation, and maintenance. Limited information was reported regarding program fidelity, adaptations, and maintenance/sustainability.

CONCLUSION

Researchers should consider the pragmatism of interventions, the nuances of program adoption and implementation at the setting level, and the transition and integration of programming into the healthcare system. Future studies may benefit from the inclusion of decision-makers and implementation experts and shifting focus towards flexible programming. PRECIS/RE-AIM may facilitate the evaluation of programs throughout the study design and implementation process.

IMPLICATIONS FOR CANCER SURVIVORS

The implementation of pragmatic exercise programs that are both scalable and sustainable is needed so that cancer survivors can experience exercise-related benefits beyond research settings.

From Cancer Rehabilitation to Recreation: A Coordinated Approach to Increasing Physical Activity

Participation in adequate physical activity improves the health status of cancer survivors, enhances their survival, and reduces their risk of cancer recurrence. However, cancer survivors engage in low levels of physical activity and have limited access to rehabilitation services that could increase their participation. No optimal framework has been developed that supports physical activity participation among cancer survivors. Given the growth in numbers of cancer survivors, development of a framework may provide a pathway to facilitate timely and appropriate care. This perspective paper describes the development of the Cancer Rehabilitation to Recreation (CaReR) Framework and its practical implications. The CaReR Framework uses a tailored, stepped approach to guide health services and clinicians on the design and implementation of interventions to promote physical activity among cancer survivors. Implementation of the CaReR Framework will improve continuity and quality of care for cancer survivors and promote physical activity with the ultimate aim of improving health outcomes.

Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer

Multiple organizations around the world have issued evidence-based exercise guidance for patients with cancer and cancer survivors. Recently, the American College of Sports Medicine has updated its exercise guidance for cancer prevention as well as for the prevention and treatment of a variety of cancer health-related outcomes (eg, fatigue, anxiety, depression, function, and quality of life). Despite these guidelines, the majority of people living with and beyond cancer are not regularly physically active. Among the reasons for this is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. The authors propose using the American College of Sports Medicine's Exercise Is Medicine initiative to address this practice gap. The simple proposal is for clinicians to assess, advise, and refer patients to either home-based or community-based exercise or for further evaluation and intervention in outpatient rehabilitation. To do this will require care coordination with appropriate professionals as well as change in the behaviors of clinicians, patients, and those who deliver the rehabilitation and exercise programming. Behavior change is one of many challenges to enacting the proposed practice changes. Other implementation challenges include capacity for triage and referral, the need for a program registry, costs and compensation, and workforce development. In conclusion, there is a call to action for key stakeholders to create the infrastructure and cultural adaptations needed so that all people living with and beyond cancer can be as active as is possible for them.

Significant Associations Between Sun Exposure and Adiposity Were Not Observed in Breast and Prostate Cancer Patients in a Cross-sectional Analysis

Obesity is a significant health problem worldwide. Exposure to low-dose ultraviolet radiation (like that in sunlight) suppresses the development of obesity in mice; however, the nature of the associations between sun exposure and adiposity is not well understood in humans. The present study characterized cross-sectional relationships between sun exposure and adiposity in a convenience cohort of breast (n = 269; mean age = 58 years) and prostate (n = 78; mean age = 69 years) cancer patients. Participants were enrolled in a 3-month exercise program in Perth, Australia. Self-reported questionnaires measured time spent outdoors (previous week, winter and summer), sex, age, treatment received and physical activity levels. Adiposity measures included body mass index, waist-hip ratio and body fat percentage (measured via DXA). In unadjusted models, greater time spent outdoors across all times was significantly associated with lower waist-hip ratio, while greater time spent outdoors in the last winter was associated with lower body fat percentage, but not when stratified by sex. There were no statistically significant associations between time spent outdoors and adiposity after adjusting for sex, age, treatments received and physical activity. Longitudinal studies in larger populations may elucidate significant associations not found in our study due to the cross-sectional design and power limitations.

An ethnographic inquiry into the psychosocial care for oncology patients in the community: Healing from the 4Es

PURPOSE

The aim of this study was to explore how the provision of community care in a cancer support center can help cancer patients and survivors cope with the demands of cancer and its treatment.

METHODS

A focused ethnographic approach was adopted. Data were collected through participant observations and focus groups with various stakeholders. The data from the focus groups were transcribed verbatim and analyzed using constant comparative analysis.

RESULTS

Four main themes emerged: 1. Enabling users to achieve mental well-being on their coping journey, 2. Empowering users to deal with their uncertainties, 3. Enhancing meaningful nurturing interactions through the design of spaces and colors in the Centre, and 4. Evolving through seeing more value in themselves. These 4Es occurred through intimate human interaction in the Centre, which resulted in psychological renewal and the rebuilding of a sense of self among the users.

CONCLUSIONS

This study provides insights on the provision of community support services for cancer patients/users, specifically on how to help them to regain control over their lives, not only through providing services for psychosocial renewal by engaging in intimate human interactions, but also by contributing to an understanding of the effect of the physical environment and space on healing. The results also reveal a virtuous circle of the 4Es as the synergies from the services, activities and the environment in the Centre, which provide a harmonious context for the users in coping with their cancer journey.

Physical activity and breast cancer survivors: Importance of adherence, motivational interviewing and psychological health

Behavioral change theories have been used to support interventions that increase both motivation for and adherence to physical activity programs for breast cancer survivors. Most of the programs can improve psychological health-related quality of life. Depressive and anxious symptoms seem to be associated with some stressors, such as the perception of breast cancer, prognosis, long-term treatment-related side-effects and fear of cancer recurrence. Beyond physical fitness, several physical activity programs for breast cancer survivors have been reported to improve psychosocial wellness and life satisfaction. However, many physical activity programs have failed to motivate breast cancer survivors due to barriers such as general health issues and lack of time. More specifically, women may have little confidence in the benefits of physical activity and breast cancer outcomes. Therefore, engaging breast cancer survivors in physical activity is challenging for health care professionals. Herein, we identify cancer-related mental distress, coping style and behavioral theories applied to physical activity programs in breast cancer survivors. More specifically, we discuss the effectiveness and limitations of 3 psychological theories and 2 concepts related to behavioral change, including the theory of planned behavior, social cognitive theory, self-determination theory, transtheoretical model and motivational interviewing for physical activity adherence in breast cancer survivors.

Effects of a Translational Community-Based Multimodal Exercise Program on Quality of Life and the Influence of Start Delay on Physical Function and Quality of Life in Breast Cancer Survivors: A Pilot Study

The purpose of this investigation was 2-fold: (1) to investigate the effects of a translational 12-week community-based multimodal exercise program on quality of life (QoL) in breast cancer survivors (BCS) and (2) to examine the influence of a start delay on physical function and QoL in BCS. Fifty-two female BCS completed a 12-week program consisting of 90-minute supervised exercise sessions at a frequency of 2 supervised sessions per week. Exercise sessions consisted of three 30-minute components: (1) aerobic conditioning, (2) resistance exercise training, and (3) balance and flexibility training. Significant ( P < .05) improvements in QoL were identified post-program completion. Cohort stratification comparison between the early start (<1 year since completion of oncologic treatment) and late start (>1 year since completion of oncologic treatment) revealed no significant ( P > .05) differences between the early start and late start groups on improvements in physical function. Regarding the influence of start delay on QoL, the early start group showed significant ( P < .05) improvement in emotional well-being. No other significant differences in improvement in QoL were detected between the early start and late start groups. Regardless of start delay, meaningful improvements in physical function and QoL were found after completing the community-based multimodal exercise program. Early participation in community-based exercise programming may benefit BCS' emotional well-being compared to later participation.