Towards a common definition of surgical prehabilitation: a scoping review of randomised trials.

BACKGROUND: There is no universally accepted definition for surgical prehabilitation. The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across randomised controlled trials and (2) propose a common definition. METHODS: The final search was conducted in February 2023 using MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. We included randomised controlled trials (RCTs) of unimodal or multimodal prehabilitation interventions (nutrition, exercise, and psychological support) lasting at least 7 days in adults undergoing elective surgery. Qualitative data were analysed using summative content analysis. RESULTS: We identified 76 prehabilitation trials of patients undergoing abdominal (n=26, 34%), orthopaedic (n=20, 26%), thoracic (n=14, 18%), cardiac (n=7, 9%), spinal (n=4, 5%), and other (n=5, 7%) surgeries. Surgical prehabilitation was explicitly defined in more than half of these RCTs (n=42, 55%). Our findings consolidated the following definition: 'Prehabilitation is a process from diagnosis to surgery, consisting of one or more preoperative interventions of exercise, nutrition, psychological strategies and respiratory training, that aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery.' CONCLUSIONS: A common definition is the first step towards standardisation, which is needed to guide future high-quality research and advance the field of prehabilitation. The proposed definition should be further evaluated by international stakeholders to ensure that it is comprehensive and globally accepted.

Outcomes reported in randomised trials of surgical prehabilitation: a scoping review.

BACKGROUND: Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation. METHODS: MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework. RESULTS: We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein. CONCLUSIONS: There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.

Enablers and barriers to referral and delivery of multidisciplinary prehabilitation in the autologous stem cell transplant population: a theory-based interview study.

PURPOSE: Health care professionals (HCP) play a vital role in effectiveness of prehabilitation programs, but information is limited about what assists HCP deliver an effective service. This study evaluated HCP perceptions of enablers and barriers to two behaviours: referral for, and delivery of, multidisciplinary prehabilitation prior to autologous stem cell transplant. METHODS: Based on the Theoretical Domains Framework (TDF) of behaviour change, we conducted semi-structured interviews, purposively sampling 14 participants (from various healthcare disciplines) at a tertiary cancer centre. Discipline-specific topic guides were created based on the TDF and the behaviours appropriate to each discipline. Interviews were audio-recorded, transcribed verbatim, anonymised, content analysed (grouping, then labelling, thematically similar responses), and classified into theoretical domains. Structured decision rules were used to classify themes as high, medium, or low priority. RESULTS: Fifty enablers and 31 barriers were identified; of these 26 enablers and 16 barriers classified as high priority. Four domains had the most frequent high-priority enablers: Social professional role and identity (e.g. multidisciplinary teamwork); Beliefs about consequences (e.g. patient benefit); Memory, attention, and decision processes (e.g. refer as early as possible); and Environmental context and resources (e.g. electronic medical records are beneficial). High-priority barriers were most frequent in four domains: Memory, attention, and decision processes (e.g. conflicting views about who should be referred); Environmental context and resources (e.g. lack of time); Social influences (e.g. families); and Emotions (e.g. patient distress). CONCLUSION: Participants reported more enablers than barriers. Findings can support delivery of prehabilitation programs in hospital settings where uptake remains low.

Self-efficacy, motivation, and habits: psychological correlates of exercise among women with breast cancer.

PURPOSE: The purpose of this analysis was to explore associations between exercise behaviour among breast cancer survivors and three behavioural constructs from distinct theories: self-efficacy from social cognitive theory, motivation from self-determination theory, and habits from habit theory. METHODS: Breast cancer survivors (n = 204) completed a cross-sectional survey that collected demographic and disease characteristics, exercise levels, and self-efficacy, motivation, and habits. Multivariable linear regression models were used to identify constructs associated with total activity and resistance training. RESULTS: Participants were a mean (SD) age of 57.3 (10.8) years and most were diagnosed with early-stage disease (72%) and engaged in sufficient levels of total activity (94%), though only 45% completed ≥ 2 resistance training sessions/week. Identified motivation (ꞵ[95% CI] = 7.6 [3.9-11.3]) and habits (ꞵ[95% CI] = 4.4 [1.4-7.4]) were significantly associated with total activity (as were body mass index and disease stage), whilst identified motivation (ꞵ[95% CI] = 0.6 [0.3-0.9]) and coping self-efficacy (ꞵ[95% CI] = 0.02 [< 0.01-0.03]) were significantly associated with resistance training. The models explained 27% and 16% of variance in total activity and resistance training behaviour, respectively. CONCLUSION: Results suggest that incorporating strategies that support identified motivation, habits, and coping self-efficacy in future interventions could promote increased exercise behaviour among breast cancer populations. Future longitudinal research should examine associations with exercise in a more representative, population-based sample.

Identifying strategies for implementing a clinical guideline for cancer-related fatigue: a qualitative study.

BACKGROUND: Clinical practice guidelines assist health professionals' (HPs) decisions. Costly to develop, many guidelines are not implemented in clinical settings. This paper describes an evaluation of contextual factors to inform clinical guideline implementation strategies for the common and distressing problem of cancer-related fatigue (CRF) at an Australian cancer hospital. METHODS: A qualitative inquiry involving interviews and focus groups with consumers and multidisciplinary HPs explored key Canadian CRF guideline recommendations. Four HP focus groups examined the feasibility of a specific recommendation, while a consumer focus group examined experiences and preferences for managing CRF. Audio recordings were analysed using a rapid method of content analysis designed to accelerate implementation research. Strategies for implementation were guided by the Consolidated Framework for Implementation Research. RESULTS: Five consumers and 31 multidisciplinary HPs participated in eight interviews and five focus groups. Key HP barriers to fatigue management were insufficient knowledge and time; and lack of accessible screening and management tools or referral pathways. Consumer barriers included priority for cancer control during short health consultations, limited stamina for extended or extra visits addressing fatigue, and HP attitudes towards fatigue. Enablers of optimal fatigue management were alignment with existing healthcare practices, increased HP knowledge of CRF guidelines and tools, and improved referral pathways. Consumers valued their HPs addressing fatigue as part of treatment, with a personal fatigue prevention or management plan including self-monitoring. Consumers preferred fatigue management outside clinic appointments and use of telehealth consultations. CONCLUSIONS: Strategies that reduce barriers and leverage enablers to guideline use should be trialled. Approaches should include (1) accessible knowledge and practice resources for busy HPs, (2) time efficient processes for patients and their HPs and (3) alignment of processes with existing practice. Funding for cancer care must enable best practice supportive care.

The role of acute in-patient rehabilitation on short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations.

BACKGROUND: The indication and surgical complexity of orthotopic liver transplantation underscore the need for strategies to optimize the recovery for transplant recipients. We conducted a systematic review aimed at identifying, evaluating, and synthesizing the evidence examining the effect of in-patient rehabilitation for liver transplant recipients and provide related practice recommendations. METHODS: Health research databases were systematically reviewed for studies that included adults who received liver transplantation and participated in acute, post-transplant rehabilitation. Postoperative morbidity, mortality, length of hospital stay, length of intensive care unit stay, and other markers of surgical recovery were extracted. Practice recommendations are provided by an international panel using GRADE. RESULTS: Twelve studies were included in the review (including 3901 participants). Rehabilitation interventions varied widely in design and composition; however, details regarding intervention delivery were poorly described in general. The quality of evidence was rated as very low largely owing to "very serious" imprecision, poor reporting, and limited data from comparative studies. Overall, the studies suggest that in-patient rehabilitation for recipients of liver transplantation is safe, tolerable, and feasible, and may benefit functional outcomes. CONCLUSION: Two practice recommendations related to in-patient rehabilitation following LT were yielded from this review: (1) it is safe, tolerable, and feasible; and (2) it improves postoperative functional outcomes. Each of the recommendations are weak and supported by low quality of evidence. No recommendation could be made related to benefits or harms for clinical, physiological, and other outcomes. Adequately powered and high quality randomized controlled trials are urgently needed in this area.

The sit-to-stand test as a patient-centered functional outcome for critical care research: a pooled analysis of five international rehabilitation studies.

BACKGROUND: With ICU mortality rates decreasing, it is increasingly important to identify interventions to minimize functional impairments and improve outcomes for survivors. Simultaneously, we must identify robust patient-centered functional outcomes for our trials. Our objective was to investigate the clinimetric properties of a progression of three outcome measures, from strength to function. METHODS: Adults (≥ 18 years) enrolled in five international ICU rehabilitation studies. Participants required ICU admission were mechanically ventilated and previously independent. Outcomes included two components of the Physical Function in ICU Test-scored (PFIT-s): knee extensor strength and assistance required to move from sit to stand (STS); the 30-s STS (30 s STS) test was the third outcome. We analyzed survivors at ICU and hospital discharge. We report participant demographics, baseline characteristics, and outcome data using descriptive statistics. Floor effects represented ≥ 15% of participants with minimum score and ceiling effects ≥ 15% with maximum score. We calculated the overall group difference score (hospital discharge score minus ICU discharge) for participants with paired assessments. RESULTS: Of 451 participants, most were male (n = 278, 61.6%) with a median age between 60 and 66 years, a mean APACHE II score between 19 and 24, a median duration of mechanical ventilation between 4 and 8 days, ICU length of stay (LOS) between 7 and 11 days, and hospital LOS between 22 and 31 days. For knee extension, we observed a ceiling effect in 48.5% (160/330) of participants at ICU discharge and in 74.7% (115/154) at hospital discharge; the median [1st, 3rd quartile] PFIT-s difference score (n = 139) was 0 [0,1] (p < 0.05). For STS assistance, we observed a ceiling effect in 45.9% (150/327) at ICU discharge and in 77.5% (79/102) at hospital discharge; the median PFIT-s difference score (n = 87) was 1 [0, 2] (p < 0.05). For 30 s STS, we observed a floor effect in 15.0% (12/80) at ICU discharge but did not observe a floor or ceiling effect at hospital discharge. The median 30 s STS difference score (n = 54) was 3 [1, 6] (p < 0.05). CONCLUSION: Among three progressive outcome measures evaluated in this study, the 30 s STS test appears to have the most favorable clinimetric properties to assess function at ICU and hospital discharge in moderate to severely ill participants.

Impact of an allied health prehabilitation service for haematologic patients receiving high-dose chemotherapy in a large cancer centre.

PURPOSE: Evaluate the impact of a new multidisciplinary allied health prehabilitation service in haematologic cancer patients receiving high-dose chemotherapy with autologous stem cell transplant (AuSCT). METHODS: In a tertiary cancer centre, 12 months of prospectively collected data was retrospectively analysed. Patients were referred to an allied health service for individualised exercise prescription, nutrition intervention and, if indicated through screening, psychological intervention. Impact and operational success were investigated using the RE-AIM framework: patient uptake of the service and sample representativeness (reach); effectiveness in terms of changes in outcomes from initial to pre-transplant assessment; adoption of the service by key stakeholders; fidelity of the prescribed exercise program (implementation); and the extent to which the new service had become routine practice (maintenance). RESULTS: One hundred and eighty-three patients were referred to the AuSCT service over 12 months, of whom 133 (73%) were referred into the prehabilitation service, 128 (96%) were eligible and 116 (91%) participated. Patients were representative of Australian AuSCT patients. Eighty-nine patients reached pre-transplant assessment by data censoring; 6-min walk distance (n = 45/89, 51%) improved a mean (95% CI) of 39.9 m (18.8 to 61.0, p = < 0.005) from baseline. Fidelity of exercise prescription was moderate with 72% of eligible patients receiving the intended exercise interventions. The referral trend over time (maintenance) was high after the initiation period. CONCLUSION: The prehabilitation service was well adopted by clinicians. Clinically relevant improvements in outcomes were demonstrated. Recommendations, including development of well-integrated discipline-specific assessment intervention and measurement protocols, are highlighted for service improvement. Prehabilitation should be routinely considered to support patients undergoing AuSCT.

Cost-effectiveness analysis of home-based rehabilitation compared to usual care for people with inoperable lung cancer.

OBJECTIVE: Few economic evaluations of lung cancer rehabilitation exist. The aim of this study was to assess the cost-effectiveness of providing home-based rehabilitation for inoperable lung cancer. METHODS: A cost-utility analysis alongside a randomised controlled trial (RCT) of rehabilitation compared with usual care. The primary outcome was quality-adjusted life years (QALYs) gained. The incremental cost-effectiveness ratio [ICER (95% CI)] and the net monetary benefit are reported. Value of information (VOI) analysis assessed the need/value of more research. RESULTS: Seventy participants (34 intervention and 36 usual care), average (SD) age 63.0 (12.0) years, 32 (45.7%) stage IV. The average intervention cost was AU$3421 (AU$5352 usual care), and effect (QALY) was 0.30 (0.31 usual care). The ICER was AU$228,197 (-1,173,194 to 1,101,450) per QALY gained. The net monetary benefit was AU$1508, favouring the intervention. The probability that the intervention was more cost-effective than usual care, at a willingness to pay threshold of AU$50,000, was 75%. VOI analysis showed that additional research to resolve decision uncertainty is potentially worthwhile. CONCLUSION: A high degree of uncertainty exists regarding the cost-effectiveness of lung cancer rehabilitation. Further RCTs, powered for economic evaluations and utilising rehabilitation sensitive outcomes, are required to support translation of evidence into clinical practice.

Implications for post critical illness trial design: sub-phenotyping trajectories of functional recovery among sepsis survivors.

BACKGROUND: Patients who survive critical illness suffer from a significant physical disability. The impact of rehabilitation strategies on health-related quality of life is inconsistent, with population heterogeneity cited as one potential confounder. This secondary analysis aimed to (1) examine trajectories of functional recovery in critically ill patients to delineate sub-phenotypes and (2) to assess differences between these cohorts in both clinical characteristics and clinimetric properties of physical function assessment tools. METHODS: Two hundred ninety-one adult sepsis survivors were followed-up for 24 months by telephone interviews. Physical function was assessed using the Physical Component Score (PCS) of the Short Form-36 Questionnaire (SF-36) and Activities of Daily Living and the Extra Short Musculoskeletal Function Assessment (XSFMA-F/B). Longitudinal trajectories were clustered by factor analysis. Logistical regression analyses were applied to patient characteristics potentially determining cluster allocation. Responsiveness, floor and ceiling effects and concurrent validity were assessed within clusters. RESULTS: One hundred fifty-nine patients completed 24 months of follow-up, presenting overall low PCS scores. Two distinct sub-cohorts were identified, exhibiting complete recovery or persistent impairment. A third sub-cohort could not be classified into either trajectory. Age, education level and number of co-morbidities were independent determinants of poor recovery (AUROC 0.743 ((95%CI 0.659-0.826), p < 0.001). Those with complete recovery trajectories demonstrated high levels of ceiling effects in physical function (PF) (15%), role physical (RP) (45%) and body pain (BP) (57%) domains of the SF-36. Those with persistent impairment demonstrated high levels of floor effects in the same domains: PF (21%), RP (71%) and BP (12%). The PF domain demonstrated high responsiveness between ICU discharge and at 6 months and was predictive of a persistent impairment trajectory (AUROC 0.859 (95%CI 0.804-0.914), p < 0.001). CONCLUSIONS: Within sepsis survivors, two distinct recovery trajectories of physical recovery were demonstrated. Older patients with more co-morbidities and lower educational achievements were more likely to have a persistent physical impairment trajectory. In regard to trajectory prediction, the PF score of the SF-36 was more responsive than the PCS and could be considered for primary outcomes. Future trials should consider adaptive trial designs that can deal with non-responders or sub-cohort specific outcome measures more effectively.

Home-based rehabilitation in inoperable non-small cell lung cancer-the patient experience.

PURPOSE: Exercise is important in lung cancer, yet most people do not meet the physical activity guidelines. The aim of this study was to characterise the views and experiences of participants with inoperable lung cancer who completed a home-based rehabilitation program. METHODS: Ninety-two participants were recruited (45 intervention group [IG], 47 usual care). Individual semi-structured interviews were conducted with participants randomised to the IG of a trial of home-based exercise, behaviour change and symptom management. Data were independently coded by two researchers, cross-checked and analysed using content analysis with a summary of arising themes. RESULTS: Of the IG (25/45), 55% were interviewed: mean (SD) age 67 (13) years; male 52%; disease stage n (%) III = 9 (36), IV = 11 (44); radical treatment intent n (%) 13 (52). The majority of participants reported program benefits, both in the physical domain (reduced sedentary time and improved strength, fitness and function) and the mental domain (motivation to keep healthy, preventing boredom). Support to self-manage symptoms was well received and many participants reported increased confidence in managing their symptoms. Exercise enablers included having expert health professional support; motivation to be stronger and better prepared for future challenges; and having an achievable and familiar program that was monitored. Treatment side-effects, pain from comorbidities and the weather were exercise barriers. For the majority of participants the use of a Fitbit™ activity tracker, text message exercise reminders and an exercise diary helped to promote adherence. CONCLUSIONS: This home-based rehabilitation program was acceptable to most participants with multiple benefits reported including improved fitness, motivation and ability to manage symptoms.

Multidisciplinary home-based rehabilitation in inoperable lung cancer: a randomised controlled trial.

BACKGROUND: Lung cancer is associated with poor health-related quality of life (HRQoL) and high symptom burden. This trial aimed to assess the efficacy of home-based rehabilitation versus usual care in inoperable lung cancer. METHODS: A parallel-group, assessor-blinded, allocation-concealed, randomised controlled trial. Eligible participants were allocated (1:1) to usual care (UC) plus 8 weeks of aerobic and resistance exercise with behaviour change strategies and symptom support (intervention group (IG)) or UC alone. Assessments occurred at baseline, 9 weeks and 6 months. The primary outcome, change in between-group 6 min walk distance (6MWD), was analysed using intention-to-treat (ITT). Subsequent analyses involved modified ITT (mITT) and included participants with at least one follow-up outcome measure. Secondary outcomes included HRQoL and symptoms. RESULTS: Ninety-two participants were recruited. Characteristics of participants (UC=47, IG=45): mean (SD) age 64 (12) years; men 55%; disease stage n (%) III=35 (38) and IV=48 (52); radical treatment 46%. There were no significant between-group differences for the 6MWD (n=92) at 9 weeks (p=0.308) or 6 months (p=0.979). The mITT analyses of 6MWD between-group differences were again non-significant (mean difference (95% CI): 9 weeks: -25.4 m (-64.0 to 13.3), p=0.198 and 6 months: 41.3 m (-26.7 to 109.4), p=0.232). Significant 6-month differences, favouring the IG, were found for HRQoL (Functional Assessment of Cancer Therapy-Lung: 13.0 (3.9 to 22.1), p=0.005) and symptom severity (MD Anderson Symptom Inventory-Lung Cancer: -2.2 (-3.6 to -0.9), p=0.001). CONCLUSIONS: Home-based rehabilitation did not improve functional exercise capacity but there were improvements in patient-reported exploratory secondary outcomes measures observed at 6 months. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12614001268639).

Improving the delivery of physical activity services in lung cancer: A qualitative representation of the patient's perspective.

OBJECTIVE: To explore patient experiences of, and preferences for, physical activity after a lung cancer diagnosis. METHODS: This was a qualitative study involving seven patients who had been treated for lung cancer within the previous 2 years. Participants attended a focus group interview. Conventional content analysis methodology was used to analyse the text by two independent researchers. RESULTS: Eight major themes emerged from the data. These were as follows: the influence of past lifestyle and chronic disease; the perceived benefits of physical activity; using physical activity to facilitate return to activities of daily living; the impact of symptoms, capacity and motivation; family and peer support; access to services; health professionals; and enjoyment of different types of physical activity. Patients suggested several factors that could improve their healthcare experience. These include access to exercise professionals particularly after cancer treatment; access to information about physical activity in different formats; supervision from health professionals and peer support; and use of behaviour change strategies to achieve sustainable increases in physical activity. CONCLUSION: Our results should be considered in the improvement of lung cancer care pathways as we strive to implement physical activity services into routine clinical care.

Utility of Mayo Clinic's early screen for discharge planning tool for predicting patient length of stay, discharge destination, and readmission risk in an inpatient oncology cohort.

PURPOSE: To examine the feasibility of using the Mayo Clinic's Early Screen for Discharge Planning (ESDP) tool in determining its predictive ability in an inpatient oncology hospital setting for variables including length of stay (LOS), discharge destination, and readmission risk. METHODS: A prospective observational study was conducted at a metropolitan tertiary cancer centre in Melbourne, Australia. The ESDP score, along with patient outcomes and characteristics, were collected to examine the relationships between positive and negative ESDP scores and patient outcomes. RESULTS: A total of 136 participants met inclusion criteria for this study. The proportion with positive ESDP scores was greater in those with unplanned hospital admissions compared with planned admissions (χ2(1, n = 136) = 3.94, p = 0.047). The ESDP status was not a significant predictor of oncology hospital LOS (rpb = 0.116, p = 0.178); however, the ESDP scores did predict discharge destination (χ2(2, n = 136) = 20.22, p < .001). Those re-admitted within 14 days were more likely to have negative ESDP scores than those not readmitted within this time period (χ2(1, n = 136) = 5.22, p = 0.022). Those with positive ESDP scores received a greater number of hospital services whilst admitted than those with negative scores (rpb = 0.388, p < .001) and were more likely to receive particular types of services. CONCLUSION: The findings from this study suggest that the ESDP tool could be useful in an adult inpatient oncology population in a hospital with defined specialised hospital discharge planning services (SHDCPS). The ESDP may be beneficial for early identification of service types likely to be required in care and likely discharge destination, both of which can assist discharge planning (DP); however, the ESDP was not useful for predicting LOS or readmission risk in the adult inpatient oncology population without a SHDCPS model in place.

Benefits of home-based multidisciplinary exercise and supportive care in inoperable non-small cell lung cancer - protocol for a phase II randomised controlled trial.

BACKGROUND: Lung cancer is one of the most commonly diagnosed cancers, and is a leading cause of cancer mortality world-wide. Due to lack of early specific symptoms, the majority of patients present with advanced, inoperable disease and five-year relative survival across all stages of non-small cell lung cancer (NSCLC) is 14%. People with lung cancer also report higher levels of symptom distress than those with other forms of cancer. Several benefits for survival and patient reported outcomes are reported from physical activity and exercise in other tumour groups. We report the protocol for a study investigating the benefits of exercise, behaviour change and symptom self-management for patients with recently diagnosed, inoperable, NSCLC. METHODS: This multi-site, parallel-group, assessor-blinded randomised controlled trial, powered for superiority, aims to assess functional and patient-reported outcomes of a multi-disciplinary, home-based exercise and supportive care program for people commencing treatment. Ninety-two participants are being recruited from three tertiary-care hospitals in Melbourne, Australia. Following baseline testing, participants are randomised using concealed allocation, to receive either: a) 8 weeks of home-based exercise (comprising an individualised endurance and resistance exercise program and behaviour change coaching) and nurse-delivered symptom self-management intervention or b) usual care. The primary outcome is the between-group difference in the change in functional exercise capacity (six-minute walk distance) from baseline to post-program assessment. Secondary outcomes include: objective and self-reported physical activity levels, physical activity self-efficacy, behavioural regulation of motivation to exercise and resilience, muscle strength (quadriceps and grip), health-related quality of life, anxiety and depression and symptom interference. DISCUSSION: There is a lack of evidence regarding the benefit of exercise intervention for people with NSCLC, particularly in those with inoperable disease receiving treatment. This trial will contribute to evidence currently being generated in national and international trials by implementing and evaluating a home-based program including three components not yet combined in previous research, for people with inoperable NSCLC receiving active treatment and involving longer-term follow-up of outcomes. This trial is ongoing and currently recruiting. TRIAL REGISTRATION: This trial was prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN12614001268639 : (4/12/14).

How is physical activity measured in lung cancer?A systematic review of outcome measures and their psychometric properties.

Physical activity (PA) levels are low in patients with lung cancer. Emerging evidence supports the use of interventions to increase PA in this population. We aimed to (1) identify and synthesize outcome measures which assess PA levels in patients with lung cancer and (2) to evaluate, synthesize and compare the psychometric properties of these measures. A systematic review of articles from searches was conducted of five electronic databases and personal records. Eligible studies were those which assessed PA using either performance-based or patient-reported measures. For aim 2, studies identified in aim 1 reporting on at least one psychometric property (validity, reliability, responsiveness or measurement error) were included. Two independent reviewers assessed eligibility and risk of bias with the COnsensus-based Standards for the selection of health status Measurement INstruments. Thirty-four studies using 21 different measures of PA were identified. Seventeen studies used performance-based measures. The Godin Leisure Time Exercise Questionnaire (GLTEQ) was the most frequently used patient-reported measure. Psychometric properties were reported for 13 of these measures and most frequently for movement sensors. Two studies reported on properties of the GLTEQ. Quality ratings for risk of bias were low. There is significant heterogeneity amongst studies regarding method of PA measurement along the lung cancer continuum. Greater consensus could be achieved by using a consensus approach such as a Delphi process. Future studies should include assessment of psychometric properties of the measurement tool being used. Currently, it is recommended where feasible, both performance-based and patient-reported measurements of PA should be undertaken.

Exercise capacity prior to major cancer surgery: A cross-sectional observational study of the validity of the 6-minute walk and 30-second sit-to-stand tests.

INTRODUCTION: Cardiopulmonary exercise testing (CPET) is the gold standard for measuring exercise capacity, however, it is resource intensive and has limited availability. This study aimed to determine: 1) the association between the 6-min walk test (6MWT) and the 30-s sit-to-stand test (30STS) with CPET peak oxygen uptake (VO2peak) and anaerobic threshold (AT) and 2) 6MWT and 30STS cut points associated with a higher risk of postoperative complications. METHODS: A cross-sectional study, retrospectively analyzing data collected from a tertiary cancer center over a 23-month period. Measures included CPET VO2peak and AT, 6MWT and 30STS test. Correlations were used to characterize relationships between variables. Receiver operating characteristic curve analyses determined 6MWT and 30STS cut points that aligned with CPET variable cut points. RESULTS: Note that, 156 participants were included. The 6MWT and 30STS displayed moderate correlations with VO2peak, rho = 0.65, p = 0.01 and rho = 0.52, p < 0.005 respectively. Fair correlations were observed between AT and 6MWT (rho = 0.36, p = 0.01) and 30STS (rho = 0.41, p < 0.005). The optimal cut points to identify VO2peak < 15 mL/kg/min were 493.5 m on the 6MWT and 12.5 stands on the 30STS test and for AT < 11 mL/kg/min were 506.5 m on the 6MWT and 12.5 stands on the 30STS test. CONCLUSION: Both the 6MWT and 30STS test could be used as alternative tools for measuring exercise capacity preoperatively in the cancer setting where CPET is not available. A range of 6MWT and 30STS cut points, according to sensitivity and specificity levels, may be used to evaluate risk of postoperative outcomes.

"The Ability to Go Out into the World Is the Most Important Thing"-A Qualitative Study of Important Exercise Outcomes for People with Lung Cancer.

Whilst existing quantitative research identifies outcomes believed to be important by researchers and clinicians, it may neglect outcomes that are meaningful to patients. This study aimed to explore the outcomes of exercise that are important to people with lung cancer and their carers. Data collection involved a qualitative methodology including semi-structured interviews and focus groups. Question guide development was informed by the International Classification of Functioning (ICF) framework. Data were analyzed by two researchers with NVivo (v12) software using a conventional content analysis process, followed by directed content analysis to map outcomes to the ICF. Conduct and reporting adhered to COREQ guidelines. Fifteen participants provided data. Most participants had received their diagnoses 24 months prior to study involvement (n = 9), and one-third had completed treatment (n = 5). Important outcomes were reported by participants across all domains of the ICF: activity and participation (n = 24), body function (n = 19), body structure (n = 5), environmental factors (n = 5), and personal factors (n = 1). Additional code categories pertained to the impacts of non-cancer factors such as age, frailty, and comorbidities; identifying barriers to exercise; and individualizing outcome measures. Clinicians and researchers should consider selecting outcomes from all relevant domains of the ICF, with a focus on the activity and participation domain, in addition to non-cancer factors such as ageing, frailty, and co-morbidities. Feedback should be provided to patients following outcome measures collection and reassessment.

Risk factors for low muscle mass, malnutrition, and (probable-) sarcopenia in adults with or without a history of cancer in the UK Biobank.

BACKGROUND AND AIMS: Early identification of people at risk of cancer-related malnutrition, low muscle mass (LMM) and sarcopenia is crucial to mitigate the impact of adverse outcomes. This study investigated risk factors associated with LMM, malnutrition and (probable-) sarcopenia and whether these varied in people with or without a history of cancer. METHODS: Participants in the UK Biobank, with or without a history of cancer, who completed the Oxford WebQ at the baseline assessment were included. LMM was estimated from fat-free mass derived from bioelectrical impedance analysis, and low muscle strength from handgrip strength, and used to identify probable or confirmed sarcopenia following the European Working Group on Sarcopenia in Older People 2 definition. The Global Leadership Initiative on Malnutrition criteria were applied to determine malnutrition. Generalised linear models were used to estimate prevalence ratios (PR) for associations between risk factors (clinical, functional, nutritional) and study outcomes. RESULTS: Overall, 50,592 adults with (n = 2,287, mean ± SD 59.7 ± 7.1 years) or without (n = 48,305, mean ± SD 55.8 ± 8.2 years) cancer were included. For all participants (PRs [cancer, without cancer]), slow walking pace (PR 1.85; 1.99), multimorbidity (PR 1.72; 1.51), inflammation (PR 2.91; 2.07), and low serum 25(OH)D (PR 1.85, 1.44) were associated with higher prevalence of LMM, while higher energy intake (PR 0.55; 0.49) was associated with lower prevalence. Slow walking pace (PR 1.54 [cancer], 1.51 [without cancer]) and higher protein intake (PR 0.18 [cancer]; 0.11 [without cancer]) were associated with increased or decreased prevalence of malnutrition, respectively regardless of cancer status. Multimorbidity was the only common factor associated with higher prevalence (PR 1.79 [cancer], 1.68 [without cancer]) of (probable-)sarcopenia in all participants. CONCLUSION: Risk factors for LMM and malnutrition were similar in adults with and without cancer, although these varied between LMM and malnutrition. These findings have implications for the future of risk stratification, screening and assessment for these conditions and the development or modification of existing screening tools.

Evaluating a Remotely Delivered Cardio-Oncology Rehabilitation Intervention for Patients With Breast Cancer (REMOTE-COR-B): Protocol for a Single-Arm Feasibility Trial.

BACKGROUND: Exercise rehabilitation is a promising strategy for reducing cardiovascular disease risk among patients with breast cancer. However, the evidence is primarily derived from programs based at exercise centers with in-person supervised delivery. Conversely, most patients report a preference for home-based rehabilitation. As such, there is a clear need to explore strategies that can provide real-time supervision and coaching while addressing consumer preferences. Evidence from cardiac rehabilitation has demonstrated the noninferiority of a smartphone-based telerehabilitation approach (REMOTE-CR) to improve cardiorespiratory fitness in people with cardiovascular disease compared to a center-based program. OBJECTIVE: This study aims to assess the feasibility, safety, and preliminary efficacy of the REMOTE-CR program adapted for patients with breast cancer at risk of cardiotoxicity (REMOTE-COR-B). We will also assess the satisfaction and usability of REMOTE-COR-B. METHODS: We will conduct a single-arm feasibility study of the REMOTE-COR-B program among patients with stage I-III breast cancer who are at risk of cardiotoxicity (taking treatment type and dose, as well as other common cardiovascular disease risk factors into account) and who are within 24 months of completing primary definitive treatment. Participants (target sample size of 40) will receive an 8-week smartphone-based telerehabilitation exercise program involving remotely delivered real-time supervision and behavior change support. The platform comprises a smartphone and wearable heart rate monitor, as well as a custom-built smartphone app and web application. Participants will be able to attend remotely monitored exercise sessions during set operating hours each week, scheduled in both the morning and evening. Adherence is the primary outcome of the trial, assessed through the number of remotely monitored exercise sessions attended compared to the trial target (ie, 3 sessions per week). Secondary outcomes include additional trial feasibility indicators (eg, recruitment and retention), safety, satisfaction, and usability, and objective and patient-reported efficacy outcomes (cardiovascular fitness, quality of life, fatigue, self-reported exercise, self-efficacy, habit strength, and motivation). Adherence, feasibility, and safety outcomes will be assessed during the intervention period; intervention satisfaction and usability will be assessed post intervention; and objective and patient-reported efficacy outcomes will be assessed at baseline, post intervention (2-month postbaseline assessment), and at follow-up (5-month postbaseline assessment). RESULTS: Recruitment for this trial commenced in March 2023, and 7 participants had been recruited as of the submission of the manuscript. The estimated completion date for the project is October 2024, with results expected to be published in mid-2025. CONCLUSIONS: The REMOTE-COR-B intervention is a novel and promising approach to providing exercise therapy to patients with breast cancer at risk of cardiotoxicity who have unique needs and heightened safety risks. This project will provide important information on the extent to which this approach is satisfactory to patients with breast cancer, safe, and potentially effective, which is necessary before larger-scale research or clinical projects. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621001557820; www.anzctr.org.au/ACTRN12621001557820.aspx. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53301.