Associations Between Physician Prescribing Behavior and Persistent Postoperative Opioid Use Among Cancer Patients Undergoing Curative-intent Surgery: A Population-based Cohort Study.

OBJECTIVE: This study aimed to evaluate the association between prescribers' opioid prescribing history and persistent postoperative opioid use in cancer patients undergoing curative-intent surgery. BACKGROUND: Study has shown that patients may be over-prescribed analgesics after surgery. However, whether and how the prescriber's opioid prescribing behavior impacts persistent opioid use is unclear. METHODS: All adults with a diagnosis of solid cancers who underwent surgery during the study period (2009-2015) in Alberta, Canada and were opioid-naïve were included. The key exposure was the historical opioid-prescribing pattern of a patient's most responsible prescriber. The primary outcome was "new persistent postoperative opioid user," was defined as a patient who was opioid-naïve before surgery and subsequently filled at least 1 opioid prescription between 60 and 180 days after surgery. RESULTS: We identified 24,500 patients. Of these, 2106 (8.6%) patients became a new persistent opioid user after surgery. Multivariate analysis demonstrated that patients with most responsible prescribers that historically prescribed higher daily doses of opioids (≥50 vs <50 mg oral morphine equivalent) had an increased risk of new persistent opioid use after surgery (odds ratio = 2.41, P < 0.0001). In addition to the provider's prescribing pattern, other factors including younger age, comorbidities, presurgical opioid use, chemotherapy, type of tumor/surgical procedure were also found to be independently associated with new persistent postoperative opioid use. CONCLUSIONS: Our results suggest that prescriber with a history of prescribing a higher opioid dose is an important predictor of persistent postoperative opioid use among cancer patients undergoing curative-intent surgery.

Symptom burden in patients with common cancers near end-of-life and its associations with clinical characteristics: a real-world study.

BACKGROUND: Patients dying with cancer can experience various physical and psychological symptoms. We aimed to determine the type and severity of symptoms within the last 6 months of life in a large real-world cohort of patients with cancer. METHODS: We examined prospectively collected patient-reported outcomes of patients with lung, colorectal, breast, prostate or pancreatic cancer using the revised Edmonton Symptom Assessment System (ESASr) questionnaire from a large province in Canada from 2016 to 2017. The ESASr was categorized into physical and psychological symptom subscores and total symptom score, and each was classified as none to mild (0-3) or moderate to severe (4-10) based on intensity. Multivariable logistic regression analyses were performed to evaluate the relationship between clinical characteristics and symptom scores. RESULTS: We identified 1159 patients eligible for analysis, of whom 52.2% were men and median age was 68 years. There were 613, 192, 149, 111 and 94 patients with lung, colorectal, breast, prostate and pancreatic cancer, respectively. While approximately half of patients reported moderate to severe physical symptom subscores and total symptom scores, only one-third reported moderate to severe psychological subscores. On multivariable logistic regression analyses, women were more likely to report moderate to severe physical (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.08-2.12; P = 0.016), psychological (OR, 1.60; 95% CI, 1.14-2.26; P = 0.006) and total symptom scores (OR, 1.80; 95% CI, 1.28-2.51; P = 0.001). Patients with lung cancer were also more likely to report moderate to severe physical and psychological subscores (OR, 1.95; 95% CI, 1.28-2.96; P = 0.002 and OR, 1.78; 95% CI, 1.13-2.81; P = 0.013) and total symptom scores (OR, 1.83; 95% CI, 1.20-2.81; P = 0.005). Finally, those closer to death were more likely to report moderate to severe physical symptom subscores (OR, 2.07; 95% CI, 1.33-3.23; P = 0.001) and total symptom scores (OR, 2.29; 95% CI, 1.46-3.60; P < 0.001), but not psychological symptom scores (OR, 1.34; 95% CI, 0.84-2.14; P = 0.210). CONCLUSIONS: There is significant symptom burden in patients with cancer near the end-of-life. Further, physical symptoms appear to be more intense than psychological symptoms. Symptom-directed care is still needed to improve the quality of end-of-life.

Associations between baseline symptom burden as assessed by patient-reported outcomes and overall survival of patients with metastatic cancer.

BACKGROUND: Serial symptom assessments using patient-reported outcomes may be challenging to implement in routine clinical practices. We aimed to determine if a single measurement of symptom burden at the time of metastatic diagnosis is associated with survival. METHODS: We examined baseline patient-reported outcomes (within 90 days of diagnosis) of patients newly diagnosed with metastatic breast, lung, colorectal, or prostate cancer using the revised Edmonton Symptom Assessment System (ESASr) questionnaire. The ESASr was categorized into physical, psychological, and total symptom domains whereby scores were classified as none to mild (0-3) or moderate to severe (4-10). Multivariable Cox proportional hazards models were constructed to evaluate the effect of baseline symptom scores on overall survival. RESULTS: We identified 1316 patients eligible for analysis. There were 181, 601, 240, and 294 patients with breast, lung, colorectal, and prostate cancer, respectively. Approximately one-quarter of all patients reported moderate to severe physical, psychological, and total symptom subscores. On multivariable Cox regression analysis, older age (P < 0.001), male sex (P = 0.002), primary lung cancer (P < 0.001), and smoking in the previous month (P = 0.007) were predictive of inferior overall survival as were baseline moderate to severe physical (hazard ratio, 1.49; 95% confidence interval, 1.16-1.90; P = 0.002) and total symptom subscores (hazard ratio, 1.38; 95% confidence interval, 1.06-1.81; P = 0.017). CONCLUSIONS: A single assessment of baseline symptom burden using the ESASr in patients with metastatic cancer has significant prognostic value. This may represent a feasible first step towards routine collection of patient-reported outcomes in real-world settings where serial symptom measurements can be challenging to implement.

Living with paradox: A qualitative study of colorectal cancer patients' experiences in managing their health after cancer treatment.

OBJECTIVES: Managing one's health after colorectal cancer may present specific challenges given long-term impacts to biopsychosocial functioning. Understanding experiences of managing one's health post-treatment is important to informing patient-centred supportive care. METHODS: A qualitative study with 19 patients who had completed treatment for colorectal cancer to explore the experience of managing one's health. Following Thorne's Interpretive Description, we conducted interviews using either focus groups or individual interviews. Transcribed data were analysed following Thorne's approach. Sociodemographic and clinical characteristics were also collected. RESULTS: The metaphor of living with paradox was the main theme characterising the experiences of managing one's health in the post-treatment period. Participants described the ambiguity of health, their need to accept the new normal, losing control and taking back control, experiencing positive and negative life changes, and the need to continually reframe their perspectives to focus on the positives. CONCLUSION: Our findings suggest that providing patient-centred care to colorectal cancer survivors post-treatment involves recognising their changing and sometimes conflicting experiences. Their ability to manage their health may fluctuate and their supportive care needs may not fit with a particular trajectory. Cancer care systems should strive for flexibility in the structure and timing of support available.

Patient-Reported Symptom Burden Near the End of Life in Patients With Gynaecologic Cancers.

OBJECTIVE: There are limited data on patient-reported outcomes near the end of life in patients with gynaecologic cancers. This study aimed to assess the symptom burden in the last 6 months of life in a real-world cohort. METHODS: Patients diagnosed with metastatic gynaecologic malignancies from 2016 to 2019 who completed the revised Edmonton Symptom Assessment System (ESASr) questionnaire within 6 months of death in a large Canadian province were identified. Patient-reported symptom scores were categorized as none to mild (0-3) and moderate to severe (4-10). Individual symptoms were subsequently grouped into physical, psychological, and total subscores. The severity of symptoms was further analyzed for any associations with age, time to death, and primary tumour site (ovarian vs. uterocervical and vulvovaginal). RESULTS: We identified 107 patients with gynaecologic malignancies including 59 ovarian, 29 uterocervical, and 19 vulvovaginal cancers. The median ages at diagnosis and questionnaire completion were 64 and 65 years, respectively. The median time from completing the ESASr questionnaire to death was 65 days. Overall, physical and psychological symptoms were moderate to severe in 57.9% and 40.2% of patients, respectively. Among the individual symptoms, tiredness was the most commonly reported moderate to severe symptom (74.9%), while shortness of breath was least commonly reported (31.6%). While physical (P < 0.001) and total symptom (P = 0.009) subscores were more likely to be moderate to severe in intensity as death approached, the psychological subscore (P = 0.744) had no relationship with time to death. Longer time to death was predictive of lower physical (P = 0.002) and total symptom (P = 0.002) subscores, while a primary uterocervical cancer site was associated with a lower psychological symptom subscore (P = 0.042). CONCLUSIONS: In the real-world setting, unique symptom trajectories can emerge for patients with gynaecologic cancer near the end of life. Knowledge of these specific symptom patterns can help inform the development and delivery of targeted palliative interventions to improve quality of life for these patients.

Patient-reported symptom burden and supportive care needs at cancer diagnosis: a retrospective cohort study.

PURPOSE: Patient-reported outcomes (PROs) are used to assess patients' symptoms and supportive care needs. While PROs are increasingly employed in clinical practice, research utilizing these data remains limited. Our goal was to evaluate PROs from a provincial cancer program. METHODS: A retrospective, population-based cohort study using administrative health data of patients in Alberta, Canada, diagnosed with cancer between January 1, 2016, and October 23, 2017. Adults who completed PROs (Edmonton Symptom Assessment System, ESAS) and supportive care needs inventory (Canadian Problem Checklist)) within ± 60 days of diagnosis were included. Patients were stratified by tumor types (breast, colorectal, lung, prostate, hematological, or other). Descriptive statistics were used to characterize symptom burden and supportive care needs. Multivariate logistic regression was used to evaluate factors associated with higher symptom severity. RESULTS: We included 1310 patients (mean age 64 years; 51% female), the majority of whom had breast (19%), lung (25%), or other cancers (26%). For the cohort, severity of symptoms based on ESAS was low, but prevalence of specific symptoms was high including tiredness (84%), anxiety (60%), pain (60%), and low well-being (80%). Seventy percent of the cohort reported at least one supportive care need. The highest-ranking problems were fears and worries and needing information about illness/treatment. There were differences across tumor types with respect to symptoms and supportive care needs. Comorbidity and having a high number of supportive care needs were associated with higher symptom severity. DISCUSSION: Our results underscore the need to develop and implement tumor-specific supportive care interventions.

Patient-level factors associated with chronic opioid use in cancer: a population-based cohort study.

PURPOSE: Concerns around chronic opioid use (COU), misuse, and harms have led to increased scrutiny of opioid prescribing in oncology. There is lack of research examining patient-level factors associated with COU. Our aim was to examine patient-level factors associated with COU in newly diagnosed cancer patients. METHODS: Population-based retrospective cohort study using administrative health data of patients in Alberta, Canada, diagnosed between February 2016 and October 2017. Adult cancer patients who completed a symptom survey within ± 60 days of diagnosis were included. Patients were divided into two groups: COU (defined as continuous opioid prescriptions for at least 90 days post-diagnosis) and non-chronic opioid use (NCOU). Logistic regression was used to evaluate factors associated with COU. RESULTS: We included 694 patients (mean age 65 years; 51% female). Most had breast (20%), colorectal (13%), and lung (33%) cancers. Of the 14% with COU, 79% were opioid naïve at diagnosis. Those in the COU group were more often diagnosed with advanced cancer (66% versus 40%), had lung cancer (47%), and were opioid tolerant (> 90 days of continuous opioids within one-year pre-diagnosis). A total of 64% of COU versus 27% of NCOU had moderate to severe pain at diagnosis (p < 0.001). Irrespective of treatment type or stage, those with moderate to severe pain, were opioid tolerant at diagnosis, or had multiple prescribers were at greater risk for COU. CONCLUSIONS: Specific patient groups were at increased risk of COU and should be the focus of adaptive prescribing approaches to ensure that opioid use is appropriate.

Self-management interventions for cancer survivors: A systematic review and evaluation of intervention content and theories.

OBJECTIVE: Self-management has been proposed as a strategy to help cancer patients optimize their health and well-being during survivorship. Previous reviews have shown variable effects of self-management on outcomes. The theoretical basis and psychoeducational components of these interventions have not been evaluated in detail. We aimed to evaluate the evidence for self-management and provide a description of the components of these interventions. METHODS: We conducted a systematic review of self-management interventions for adults who had completed primary cancer treatment by searching MEDLINE, EMBASE, PsychINFO, CINAHL, Scopus, Cochrane Database of Systematic Reviews, National Institutes of Health Clinical Trials Registry, and Cochrane CENTRAL Registry of Controlled Trials. We included experimental and quasiexperimental designs. Data synthesis included narrative and tabular summary of results; heterogeneity of interventions and outcomes precluded meta-analysis. Study quality was evaluated using the Cochrane risk of bias tool or the risk of bias of nonrandomized studies tool. RESULTS: Forty-one studies published between 1994 and 29 March 2018 were included. Studies were predominantly randomized controlled trials and targeted to breast cancer survivors. A variety of intervention designs, psychoeducational components, and outcomes were identified. Less than 50% of the studies included a theoretical framework. There was variability of effects across most outcomes. Risk of bias could not be fully assessed. CONCLUSIONS: There are limitations in the design and research on self-management interventions for cancer survivors that hinder their translation into clinical practice. Further research is needed to understand if these interventions are an important type of support for cancer survivors.

The Effects of Exercise on Physical and Psychological Outcomes in Cancer Caregivers: Results From the RECHARGE Randomized Controlled Trial.

Background: Family caregivers to cancer patients are at risk for physical and psychological morbidity as a direct result of being in the caregiver role. Exercise as an intervention to support caregiver health and well-being has been tested in other caregiver populations; however, no randomized controlled trials testing the effects of an aerobic and resistance training program have been conducted where cancer caregivers only have participated. Purpose: To examine the effects of a 12-week exercise program on quality of life (Short Form 36 v2), psychological outcomes, physical activity levels, and physical fitness in caregivers to cancer patients. Methods: Seventy-seven caregivers were randomized to either an exercise intervention or wait-list control. Two participants in the exercise arm dropped out immediately after their baseline assessment. Outcome data for n = 77 participants were analyzed using intention-to-treat analysis with linear mixed models. Results: Significant group by time interaction effects were detected for exercise on the mental health component score of quality of life, self-reported weekly exercise levels, and the six-minute walk test. Small to medium effect sizes were detected on several outcomes including physical health component of quality of life (d = 0.36), mental health component of quality of life (d = 0.74), depression (d = 0.41), anxiety (d = 0.35), physical activity levels (d = 0.80), and the six-minute walk test (d = 0.21). Conclusions: The findings suggest that exercise may improve health and well-being and could be considered as an additional type of support offered to cancer caregivers. Clinical trial registration no: NCT02580461.

Feasibility of using the Multinational Association of Supportive Care in Cancer Antiemesis Tool for assessment of chemotherapy-induced nausea and vomiting at the Tom Baker Cancer Centre.

INTRODUCTION: Chemotherapy-induced nausea and vomiting (CINV) has been shown to adversely impact patient anxiety, quality of life, treatment adherence, and use of health care resources. CINV control still remains a challenge, and lack of effective communication between the patient and clinician has been highlighted in the literature as the main barrier to optimal control. The Multinational Association of Supportive Care in Cancer (MASCC) has developed a tool (MASCC Antiemesis Tool (MAT)) to improve assessment and subsequent management of CINV by enhancing communication between patients and their clinicians. This study assessed the feasibility of using the MAT in patients at the Tom Baker Cancer Centre. The secondary objective was to describe the incidence of CINV as identified by the tool. METHODS AND MATERIALS: This study involved a prospective survey using the MAT in patients receiving intravenous chemotherapy. Subjects completed the MAT twice post-chemotherapy regarding CINV symptoms and returned it at their next clinic appointment. Participants were also surveyed to evaluate feasibility with regard to using the MAT. RESULTS: Of the 50 patients recruited, 56% returned surveys. The majority of patients reported that the MAT facilitated communication with their clinician, particularly those who had experienced CINV. Fifty-four percent of patients who returned the MAT reported CINV; however, less than half of them had received American Society of Clinical Oncology-recommended antiemetic regimens. Only four patients with CINV had antiemetic changes made for subsequent cycles. CONCLUSION: The MAT is a feasible tool which can improve communication of CINV symptoms between patients and clinicians, a foundational step toward improving CINV management.

Patient-Reported Symptom Burden and Supportive Care Needs of Patients With Stage II-III Colorectal Cancer During and After Adjuvant Systemic Treatment: A Real-World Evidence Study.

PURPOSE: Patients with colorectal cancer (CRC) experience a range of physical and psychologic symptoms, and supportive care needs throughout the illness trajectory. We used patient-reported outcomes and administrative health data to describe symptom burden and supportive care needs during and after adjuvant treatment and determine factors associated with changes to symptom burden. METHODS: A retrospective population-based cohort study of patients who were newly diagnosed with stage II-III CRC in Alberta, Canada, between January 1, 2016, and January 31, 2019. Adults age 18 years or older who completed a patient-reported outcomes survey (Edmonton Symptom Assessment System) and supportive care needs (Canadian Problem Checklist) within 3 months after starting adjuvant treatment (during treatment) and > 7 months after starting treatment (after treatment) were included. Changes to symptom severity were stratified as stable, improved, or deteriorated. Multivariable logistic regression was used to evaluate factors associated with these changes. RESULTS: We included 303 patients (median age 60 years, 62% male, 84.5% stage III, 51.2% rectal v colon). Prevalent symptoms included tiredness (80.5%), pain (50.8%), and poor well-being (50%) during treatment, and tiredness (71.3%), pain (44.2%), and poor well-being (62.1%) after treatment. The results were heterogeneous with respect to improvements, stability, or deterioration. Pain worsened for 25% of the cohort, tiredness for 28%, and depression, anxiety, and well-being for 21%, 22%, and 31%, respectively. Deterioration of some symptoms was associated with older age, stage II, comorbidities, rural setting, and higher income. CONCLUSION: We demonstrated symptom severity was generally low and most symptoms remained stable or improved after treatment. Particular groups of patients were at greater risk for more severe and/or more persistent symptoms. Ongoing assessments and interventions to address physical and psychologic symptoms, and supportive care needs in patients with CRC during and after treatment are needed.

Association Between Adjuvant Chemotherapy Duration and Survival Among Patients With Stage II and III Colon Cancer: A Systematic Review and Meta-analysis.

Importance: The results from the recent International Duration Evaluation of Adjuvant Therapy (IDEA) collaboration have led some clinicians to adopt shorter durations of adjuvant chemotherapy for patients with stage III colon cancer. The extent to which these findings are supported by other data is unknown. Objective: To conduct a systematic review and meta-analysis of randomized and observational studies investigating the association between the duration of adjuvant chemotherapy and survival among individuals diagnosed as having stage II and III colon cancer (PROSPERO protocol CRD42018108711]). Data Sources: Abstracts published in English between 2003 and 2018 within the MEDLINE, Embase, CENTRAL, and CINAHL databases were reviewed by 2 authors. Also searched were conference proceedings and the indexes of high-impact oncology journals. Study Selection: Studies were excluded if they did not present original data; focused on animal populations, on cancers in sites other than the colon, or on patients with stage 0, I, or IV disease; did not examine a 5-flourouracil-based monotherapy or combination therapy; or did not evaluate the association between treatment duration and survival. The search identified 2341 articles, from which 2 randomized trials and 20 observational studies were included in the meta-analysis. Data Extraction and Synthesis: This study followed the PRISMA and MOOSE reporting guidelines. The risk of bias was assessed by 2 authors using the Cochrane and Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tools. The results were synthesized using a random-effects model. Main Outcomes and Measures: The primary and secondary outcomes were overall survival and disease-free survival, respectively. It was hypothesized a priori that 3 months of chemotherapy would be as effective as 6 months of chemotherapy. Results: Twenty-two studies were included in the meta-analysis, representing 43 671 patients. The inclusion of patients with stage II disease or with rectal cancer was identified as a source of heterogeneity. After restricting the analysis to patients with stage III colon cancer, there was no association between the duration of chemotherapy and overall survival among studies involving FOLFOX (leucovorin calcium [folinic acid], fluorouracil, and oxaliplatin) or CAPOX (capecitabine plus oxaliplatin) regimens (hazard ratio [HR], 0.80; 95% CI, 0.58-1.09). Among studies focused exclusively on monotherapy, the standard 6-month regimen relative to a 3-month regimen was associated with improved survival (HR, 0.59; 95% CI, 0.52-0.68). Conclusions and Relevance: Shortened durations of chemotherapy may reduce survival among patients with stage III colon cancer prescribed monotherapy but not a combination regimen.

The effect of comorbidities on outcomes in colorectal cancer survivors: a population-based cohort study.

PURPOSE: To examine the prevalence of comorbidities and the association of these comorbidities with demographics, tumor characteristics, treatments received, overall survival, and causes of death in a population-based cohort of colorectal cancer (CRC) patients. METHODS: Adult patients with stage I-III CRC diagnosed between 2004 and 2015 were included. Comorbidities were captured using Charlson comorbidity index. Causes of death were categorized using International Classification of Diseases, tenth revision codes. Patients were categorized into five mutually exclusive comorbid groups (cardiovascular disease alone, diabetes alone, cardiovascular disease plus diabetes, other comorbidities, or no comorbidities). Data were analyzed using descriptive statistics, Kaplan-Meier survival analyses, and Cox proportional hazards models. RESULTS: There were 12,265 patients. Mean follow-up was 3.8 years. Approximately one third of patients had a least one comorbidity, with cardiovascular disease and diabetes being most common. There were statistically significant differences across comorbid groups on treatments received and overall survival. Those with comorbidity had lower odds of treatment and greater risk of death than those with no comorbidity. Those with cardiovascular disease plus diabetes fared the worst for prognosis (median overall survival 3.3 [2.8-3.7] years; adjusted HR for death, 2.27, 95% CI 2.0-2.6, p < .001). Cardiovascular disease was the most common cause of non-CRC death. CONCLUSIONS: CRC patients with comorbidity received curative intent treatment less frequently and experienced worse outcomes than patients with no comorbidity. Cardiovascular disease was the most common cause of non-cancer death. IMPLICATIONS FOR CANCER SURVIVORS: Management of comorbidities, including healthy lifestyle coaching, at diagnosis and into survivorship is an important component of cancer care.

What is the State of the Science on Physical Activity Interventions for Family Caregivers? A Systematic Review and RE-AIM Evaluation.

BACKGROUND: Family caregivers are an important health care resource and represent a significant proportion of Canadian and US populations. Family caregivers suffer physical and psychological health problems because of being in the caregiver role. Interventions to support caregiver health, including physical activity (PA), are slow to be investigated and translated into practice. PURPOSE: To examine the evidence for PA interventions in caregivers and determine factors hampering the uptake of this evidence into practice. METHODS: A systematic review and evaluation of internal and external validity using the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework was conducted. Randomized controlled trials or pretest/posttest studies of PA interventions were included. RESULTS: Fourteen studies were published between 1997 and 2015. Methodological quality of studies and risk of bias was variable. External validity criteria were often not reported. Mean reporting levels were 1) reach, 53%; 2) efficacy/effectiveness, 73%; 3) adoption, 18%; 4) implementation, 48%; and 5) maintenance, 2%. CONCLUSIONS: The lack of reporting of components of internal and external validity hinders the integration of caregiver PA interventions into clinical or community settings. Researchers should focus on standardized outcomes, accepted reporting criteria, and balancing factors of internal and external validity, to advance the state of the science.

Exploring Gender Differences in Self-Reported Physical Activity and Health Among Older Caregivers.

PURPOSE/OBJECTIVES: To document self-reported physical health and activity levels of older caregivers. Gender differences in physical health, physical activity levels, and predictors of physical activity were also examined.
. DESIGN: A cross-sectional study.
. SETTING: Tom Baker Cancer Centre in Calgary, Alberta, Canada.
. SAMPLE: 130 caregivers aged 60 years or older caring for individuals with breast, prostate, or colorectal cancer.
. METHODS: Self-report survey including validated questionnaires on physical and mental health and physical activity levels. Convenience sampling was used. Data were analyzed using descriptive statistics, correlations, and multiple regression.
. MAIN RESEARCH VARIABLES: The physical component score of the SF-36v2® was the main research variable. Other variables included the mental component score of the SF-36v2, sleep quality, depression, social support, physical activity levels, and anxiety.
. FINDINGS: The mean age of caregivers was 70 years. Physical health and physical activity levels were higher than population norms. A significant difference in physical health (p = 0.015) existed between men and women but not in physical activity levels (p = 0.079). Predictors of physical activity levels were age (ß = -0.291), physical health (ß = 0.307), and caregiving hours per week (ß = -0.221).
. CONCLUSIONS: The findings suggest that gender had a minimal effect on physical health and no effect on physical activity levels in older caregivers. Depression and poor sleep quality were high in some caregivers but did not predict physical activity levels. 
. IMPLICATIONS FOR NURSING: The negative effects of caregiving on physical health and physical activity levels in older caregivers are not universal. Nurses should be aware of the caregiving situation and promote health based on the individual.

Renewing caregiver health and wellbeing through exercise (RECHARGE): A randomized controlled trial.

BACKGROUND: Family caregivers (FCs) to cancer patients are at increased risk for physical and emotional health problems as a result of being in the caregiver role. Current research on interventions for FCs has focused on psychological support or educational interventions, with very little investigation of exercise in maintaining or improving health. Based on our preliminary survey, participation in regular exercise to improve health was noted as a priority for FCs. The purpose of the study described in this protocol is to examine the impact of a 12-week structured exercise program on physical functioning (primary outcome), physical activity levels and psychological well-being (secondary outcomes), in FCs caring for adult cancer patients. In addition, the trial described here will examine the outcomes from a 12-week maintenance program, immediately following the initial program. METHODS/DESIGN: A mixed methods design using a randomized control trial (RCT) with a 50/50 allocation ratio for the quantitative portion, followed by face to face interviews and qualitative data analysis. Approximately 86 participants will be enrolled over a 10 month period. The intervention will consist of a structured exercise program of aerobic and resistance training. An intention to treat principle using mixed effects modeling will guide data analysis. DISCUSSION: FCs will continue to play a pivotal role in the care of cancer patients as the incidence and chronicity of cancer increases. The research described in this protocol will provide information about the impact of an exercise program in supporting FC health. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02580461.