PERSPECTIVEs on supervised exercise programs in people with metastatic breast cancer- a qualitative study in four European countries.

PURPOSE: Supervised exercise is a potentially promising supportive care intervention for people with metastatic breast cancer (MBC), but research on the patients' perspective is limited. The aim of the current focus group study was to gain an in-depth understanding of MBC patients' perceived barriers, facilitators, and preferences for supervised exercise programs. METHODS: Eleven online focus groups with, in total, 44 MBC patients were conducted in four European countries (Germany, Poland, Spain, Sweden). Main topics of the semi-structured discussions covered attitudes towards participation in supervised exercise programs, perceived facilitators, experienced barriers, and exercise preferences. Interviews were transcribed verbatim, translated into English, and coded based on a preliminary coding framework, supplemented by themes emerging during the sessions. The codes were subsequently examined for interrelations and re-organized into overarching clusters. RESULTS: Participants had positive attitudes towards exercise, but experienced physical limitations and insecurities that inhibited their participation. They expressed a strong desire for exercise tailored to their needs, and supervision by an exercise professional. Participants also highlighted the social nature of group training as an important facilitator. They had no clear preference for exercise type, but rather favored a mixture of different activities. Flexible training modules were considered helpful to increase exercise program adherence. CONCLUSIONS: MBC patients were generally interested in supervised exercise programs. They preferred group exercise that facilitates social interaction, but also expressed a need for individualized exercise programs. This suggests the relevance to develop flexible exercise programs that are adjusted to the individual's needs, abilities, and preferences.

Perspectives of patients with metastatic breast cancer on physical exercise programs: results from a survey in five European countries.

BACKGROUND: To successfully implement exercise programs for patients with metastatic breast cancer (MBC), services and patient education should consider patients' knowledge, preferences, values, and goals. Hence, gaining insight into their perspectives on exercise and exercise programming is important. METHOD: In this cross-sectional survey, we recruited patients with MBC from the Netherlands, Germany, Poland, Spain, and Sweden. We collected data on patients' knowledge and skills about exercise and outcome expectations. We identified barriers to and facilitators of participation in exercise programs, and patients' preferences for program content and modes of exercise delivery. RESULTS: A total of 420 patients participated in the survey. Respondents were, on average, 56.5 years old (SD 10.8) and 70% had bone metastases. Sixty-eight percent reported sufficient skills to engage in aerobic exercise, but only 35% did so for resistance exercise. Respondents expected exercise to have multiple physical benefits, but a few patients expected exercise to worsen their pain (5%). Not having access to an exercise program for cancer patients (27%), feeling too tired (23%), and/or weak (23%) were the most often reported barriers. Facilitators for exercising regularly were previous positive physical (72%) and emotional (68%) experiences with exercising, and receiving personalized advice from a physiotherapist or sport/fitness instructor (62%). Patients were most interested in walking and preferred exercising at a public gym, although there were differences by country. Fifty-seven percent did not know whether their insurance company reimburses exercise programs and only 9% would be willing to pay more than €50 per month to participate. CONCLUSION: A large percentage of patients with MBC lack the skills to engage in regular exercise as recommended by exercise guidelines for people with cancer. Patients may benefit from personalized advice and appropriate training facilities to overcome barriers. When implementing exercise interventions, attention should be given to reimbursement and the relatively low willingness-to-pay.

Impact and Determinants of Structural Barriers on Physical Activity in People with Cancer.

BACKGROUND: A better understanding of the role of structural barriers for physical activity (PA) after a cancer diagnosis could help to increase PA among people with cancer. Thus, the present study aimed to identify determinants of structural barriers to PA in people with cancer and investigate the association between structural barriers and insufficient post-diagnosis PA, taking different PA change patterns into account. METHODS: A total of 1299 people with breast, prostate, or colorectal cancer completed a questionnaire assessing their socio-demographic and medical characteristics, pre- and post-diagnosis PA, and perceived PA impediment by seven structural barriers. Regression analyses were used to investigate determinants of the perception of structural barriers and to examine the association between structural barriers and insufficient post-diagnosis PA, also with regard to different pre-diagnosis PA levels. RESULTS: Overall 30-60% of participants indicated to feel impeded by structural barriers. The analyses revealed a younger age, higher BMI, lower educational level, no current work activity, co-morbidities, and lacking physicians' exercise counseling as significant determinants of the perception of structural barriers. Individuals reporting stronger impediments by structural barriers were significantly less likely to be meeting PA guidelines post-diagnosis, particularly those with sufficient pre-diagnosis PA levels. CONCLUSIONS: The study highlights the need for tailored PA programs for people with cancer as well as for more guidance and support in overcoming structural barriers to improve PA behavior. The study has been registered under NCT02678832 at clinicaltrials.gov on February 10th 2016.

Using wearables to promote physical activity in old age : Feasibility, benefits, and user friendliness.

BACKGROUND: Wearables provide new opportunities to promote physical activity also among older adults but data on effectiveness and user friendliness are rare. OBJECTIVE: The effects of a comprehensive self-regulative intervention on moderate to vigorous physical activity (MVPA) and number of steps were examined using commercially available activity trackers. Acceptance regarding the devices was analysed in various domains. METHODS: In this study 80 older adults (mean = 67.03 years, standard deviation = 3.97 years; 59% women) wore a Fitbit Charge HR for 21 days including a baseline, a postintervention and a follow-up week. The intervention comprised feedback, goal setting and planning and 50% of the participants were additionally randomized to a role model component. Social cognitive predictors based on the health action process approach (HAPA) and user experience were assessed via questionnaires. RESULTS: The MVPA increased by an average of 19 min per week and steps by 1317 per day. An additional benefit of the role model component could be observed for MVPA. In the follow-up, the intervention effect was still significant for the number of steps, while MVPA dropped back to baseline. Multilevel models including HAPA variables explained small but significant amounts of variance in MVPA (8% within-person, 26% between-person) and steps (11% within-person, 12% between-person). User experience was rated as very high. CONCLUSION: Providing an intervention based on established behavior change techniques and self-monitoring via wearables seems to be effective for increasing physical activity among older adults. The HAPA variables seem to play a limited role to explain activity levels. Acceptance of wearables can be expected to be high.

The association between physicians' exercise counseling and physical activity in patients with cancer: Which roles do patients' satisfaction and previous physical activity levels play?

OBJECTIVES: The purpose of this study was to examine the association between physicians' exercise counseling and post-diagnosis physical activity (PA) in patients with cancer by investigating the mediating role of patients' satisfaction with exercise counseling as well as the moderating role of patients' previous PA. METHODS: The study sample consisted of 1002 people with cancer (503 breast, 265 prostate, and 234 colorectal cancer). Participants reported their pre- and post-diagnosis moderate-to-vigorous PA (MVPA) levels, indicated whether their physician had covered different steps of exercise counseling as defined by the 5A framework (Assess, Advise, Agree, Assist, and Arrange) and rated their satisfaction with exercise counseling. A conditional process analysis was used to determine the direct and indirect effects of counseling on post-diagnosis MVPA through satisfaction at different levels of pre-diagnosis MVPA. RESULTS: Physicians' exercise counseling was associated with post-diagnosis MVPA in patients with cancer. However, the association differed by patients' pre-diagnosis MVPA (P = .039). While counseling was directly associated with higher post-diagnosis MVPA for individuals with low pre-diagnosis MVPA (CI: 0.02-0.20, P = .014), the effect was mediated through satisfaction with exercise counseling for previously highly active individuals (Boot CI: 0.01-0.08). CONCLUSIONS: Our findings emphasize the relevance of physicians' exercise counseling for PA in patients with cancer. However, the results indicate that in order to effectively influence patients' PA, it appears important to provide a comprehensive counseling that is adjusted to the patients' exercise experiences.

Change patterns and determinants of physical activity differ between breast, prostate, and colorectal cancer patients.

PURPOSE: The purpose of this study was to examine and compare pre- to post-diagnosis change patterns of physical activity (PA) among breast, prostate, and colorectal cancer patients. Moreover, the study aimed to investigate sociodemographic and medical determinants of post-diagnosis PA and to identify patient subgroups at increased risk of inactivity. METHODS: A total of 912 cancer patients (457 breast, 241 prostate, 214 colorectal cancer) completed a questionnaire assessing their pre- and post-diagnosis PA behavior, and sociodemographic and medical variables. Age-adjusted regression and classification tree analyses were used to investigate PA determinants and detect subgroups that were most likely to meet or not meet PA guidelines. RESULTS: Across cancer types, we found that PA yet decreased from pre- to post-diagnosis, but that 54.1% of participants still reported to be meeting PA guidelines after the diagnosis. While post-diagnosis PA was strongly affected by previous PA behavior among individuals of all patient groups, other sociodemographic and medical determinants played different roles depending on cancer type. The results yielded that previously active, longer diagnosed patients with higher education levels were most likely to be meeting PA guidelines post-diagnosis, whereas specifically previously inactive prostate cancer patients had an increased likelihood of insufficient activity. CONCLUSIONS: An encouragingly high number of cancer patients indicated sufficient PA levels. For those having difficulties to maintain or adopt PA post-diagnosis, interventions should be tailored to the specific characteristics of each cancer type, as different factors are associated with PA for each patient group.

Dutch prostate cancer patients' views about exercise and experience with exercise advice: a national survey.

PURPOSE: To support the development and implementation of exercise programming for people with prostate cancer (PC), we investigated their views on exercise. METHODS: Online survey with open recruitment. We collected data on clinical and sociodemographic variables, experiences with exercise advice, outcome expectations, and preferences. We explored determinants of (1) having been counselled about exercise and (2) preferring supervised exercise. RESULTS: The survey was completed by 171 patients (mean age = 70 years, SD = 6.5) from all PC treatment pathways. Sixty-three percent of the respondents reported never having been informed about the potential benefits of exercise. Forty-nine percent preferred exercise to be supervised. Respondents generally reported a positive attitude towards exercise. Seventy-four percent indicated barriers to exercising, including fatigue and lack of access to specific programmes. Outcome expectations were generally positive but moderately strong. Receiving hormonal therapy and younger age were significantly associated with having received exercise advice. Being insured and having higher fatigue levels contributed significantly to the preference for supervised exercise. CONCLUSION: Dutch people with PC report receiving insufficient effective exercise counselling. Yet, they are open to exercise and expect exercise to improve their health, although they experience various barriers that limit their ability to exercise. IMPLICATIONS FOR CANCER SURVIVORS: The moderate outcome expectations for exercise of people with PC and their limited recall of exercise counselling highlight the need for better integration of exercise in clinical pathways. The lack of access to specific programming limits the use of evidence-based exercise programmes for people with PC.

The Relationship between Exercise Self-Efficacy, Intention, and Structural Barriers for Physical Activity after a Cancer Diagnosis.

Previous research has shown that structural barriers negatively influence the physical activity (PA) behavior of cancer patients, but underlying mechanisms are unclear. The aim of the current study was to explore the potential mediating role of social-cognitive factors, namely PA self-efficacy and PA intention in this context. A total of 856 cancer patients completed a questionnaire on sociodemographic and medical characteristics, pre- and post-diagnosis PA, PA self-efficacy, PA intention, and PA impediment by structural barriers. A serial mediation model was used to test whether the association between structural barriers and post-diagnosis PA was mediated by PA self-efficacy and/or PA intention, in the overall sample and in subsamples defined by individuals' pre-diagnosis PA. The results confirmed that structural barriers were not directly (95%CI [-0.45; 0.10]) but indirectly associated with post-diagnosis PA. Higher impediment by structural barriers decreased the likelihood of sufficient post-diagnosis PA via lower PA self-efficacy (95%CI [-0.25; -0.06]) and via the serial pathway of lower PA self-efficacy and lower PA intention (95%CI [-0.19; -0.05]). Investigating differences in these mediations by pre-diagnosis PA yielded significance only among previously active cancer patients. Both structural barriers and PA self-efficacy might hence be relevant target points for interventions aiming to improve PA behavior, especially among pre-diagnosis active cancer patients.

Design of a multinational randomized controlled trial to assess the effects of structured and individualized exercise in patients with metastatic breast cancer on fatigue and quality of life: the EFFECT study.

BACKGROUND: Many patients with metastatic breast cancer experience cancer- and treatment-related side effects that impair activities of daily living and negatively affect the quality of life. There is a need for interventions that improve quality of life by alleviating fatigue and other side effects during palliative cancer treatment. Beneficial effects of exercise have been observed in the curative setting, but, to date, comparable evidence in patients with metastatic breast cancer is lacking. The aim of this study is to assess the effects of a structured and individualized 9-month exercise intervention in patients with metastatic breast cancer on quality of life, fatigue, and other cancer- and treatment-related side effects. METHODS: The EFFECT study is a multinational, randomized controlled trial including 350 patients with metastatic breast cancer. Participants are randomly allocated (1:1) to an exercise or control group. The exercise group participates in a 9-month multimodal exercise program, starting with a 6-month period where participants exercise twice a week under the supervision of an exercise professional. After completing this 6-month period, one supervised session is replaced by one unsupervised session for 3 months. In addition, participants are instructed to be physically active for ≥30 min/day on all remaining days of the week, while being supported by an activity tracker and exercise app. Participants allocated to the control group receive standard medical care, general written physical activity advice, and an activity tracker, but no structured exercise program. The primary outcomes are quality of life (EORTC QLQ-C30, summary score) and fatigue (EORTC QLQ-FA12), assessed at baseline, 3, 6 (primary endpoint), and 9 months post-baseline. Secondary outcomes include physical fitness, physical performance, physical activity, anxiety, depression, pain, sleep problems, anthropometric data, body composition, and blood markers. Exploratory outcomes include quality of working life, muscle thickness, urinary incontinence, disease progression, and survival. Additionally, the cost-effectiveness of the exercise program is assessed. Adherence and safety are monitored throughout the intervention period. DISCUSSION: This large randomized controlled trial will provide evidence regarding the (cost-) effectiveness of exercise during treatment of metastatic breast cancer. If proven (cost-)effective, exercise should be offered to patients with metastatic breast cancer as part of standard care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04120298 . Registered on October 9, 2019.

Physical activity counseling to cancer patients: How are patients addressed and who benefits most?

OBJECTIVE: This study examined cancer patients' reporting on physicians' physical activity (PA) counseling, its associations with patients' PA, and comparisons of patients' and physicians' reports of the type(s) of PA counseling provided. METHODS: Patients with breast, colorectal, or prostate cancer (n = 1206) participated in a nationwide cross-sectional study. Cancer patients' sociodemographic and treatment-related characteristics as well as self-reported PA levels (pre- and post-diagnosis) were assessed. PA counseling was queried according to the counseling steps of the 5As framework (Assess/Advise/Agree/Assist/Arrange). For a subsample (n = 135), matched patient-physician data were available. RESULTS: Patient-reported PA counseling was categorized into "no counseling" (indicated by 20.8% of participants), "basic counseling" (Assess and/or Advise; 58.8%), and "in-depth counseling" (Agree, Assist, and/or Arrange; 20.4%). "In-depth counseling" was associated with an increase in PA levels pre- to post-diagnosis. This relationship was enhanced for patients with metastases. There were low agreements between patients' and physicians' reporting of PA counseling steps. CONCLUSION: In-depth PA counseling is rarely provided to cancer patients but seems to be required to affect PA levels. Patients often report receiving less intensive PA counseling than reported by their physician. PRACTICE IMPLICATIONS: Physicians should be enabled to provide routine in-depth PA counseling to all patients with cancer.