Development of the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) algorithm.

PURPOSE: Participation in exercise or rehabilitation services is recommended to optimize health, functioning, and well-being across the cancer continuum of care. However, limited knowledge of individual needs and complex decision-making are barriers to connect the right survivor to the right exercise/rehabilitation service at the right time. In this article, we define the levels of exercise/rehabilitation services, provide a conceptual model to improve understanding of individual needs, and describe the development of the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) algorithm. METHODS: From literature review, we synthesized defining characteristics of exercise/rehabilitation services and individual characteristics associated with safety and efficacy for each service. We developed a visual model to conceptualize the need for each level of specialized care, then organized individual characteristics into a risk-stratified algorithm. Iterative review with a multidisciplinary expert panel was conducted until consensus was reached on algorithm content and format. RESULTS: We identified eight defining features of the four levels of exercise/rehabilitation services and provide a conceptual model of to guide individualized navigation for each service across the continuum of care. The EXCEEDS algorithm includes a risk-stratified series of eleven dichotomous questions, organized in two sections and ten domains. CONCLUSIONS: The EXCEEDS algorithm is an evidence-based decision support tool that provides a common language to describe exercise/rehabilitation services, a practical model to understand individualized needs, and step-by-step decision support guidance. The EXCEEDS algorithm is designed to be used at point of care or point of need by multidisciplinary users, including survivors. Thus, implementation may improve care coordination for cancer exercise/rehabilitation services.

Women's Experiences After Ovarian Cancer Surgery: Distress, Uncertainty, and the Need for Occupational Therapy.

IMPORTANCE: Despite the growing literature on the association of functional, physical, and quality-of-life (QOL) deficits with poor postoperative outcomes, there is a gap in the literature identifying women's occupational performance needs after ovarian cancer surgery. OBJECTIVE: To describe the experiences of women hospitalized after ovarian cancer surgery to identify potential areas for intervention. Goals were to (1) identify functional needs and limitations at time of discharge as measured by the typical acute care occupational therapy evaluation and semistructured interview and (2) understand the women's perspectives of their needs for occupational therapy and a safe return to home. DESIGN: Single-arm, cross-sectional descriptive study. Mixed-methods data collection and analysis. SETTING: Academic cancer center. PARTICIPANTS: Women with ovarian cancer (N = 11) who had completed surgery. INTERVENTION: Semistructured interviews and patient-reported outcome measures (PROMs) completed postsurgery. OUTCOMES AND MEASURES: PROMs included the National Comprehensive Cancer Network (NCCN) Distress Thermometer and Problem List, the PROMIS® Global Physical Health (GPH) and Global Mental Health (GMH) scales, and the Possibilities for Activity Scale-Women (PActS-W). RESULTS: The mean NCCN Distress score was 6.0 (standard deviation [SD] = 3.1, with the top three concerns being pain (80%), worry (80%), and fatigue (78%). Mean GPH and GMH T scores were 38.0 (SD = 8.8) and 48.2 (SD = 8.4), respectively. Women scored a mean of 39.2 (SD = 11.2, range = 26-58) on the PActS-W. Thematic analyses found that the women were uncertain about potential functional limitations and significantly distressed. CONCLUSION AND RELEVANCE: Women with ovarian cancer experienced high levels of uncertainty and distress after surgery. Integrating in-home or community-based occupational therapy into routine care could decrease functional distress and uncertainty and help women manage concerns related to pain, worry, and fatigue. WHAT THIS ARTICLE ADDS: This study suggests that occupational therapy evaluation and intervention are needed to decrease distress and improve QOL of women upon discharge after ovarian cancer surgery.

Understanding fall risk for older adults with cancer: An evaluation of experts' perceptions.

OBJECTIVE: Older adults with cancer have elevated risk of falling. However, cancer-specific fall risk factors are not well understood. METHODS: A pragmatic, qualitative study utilized semi-structured interviews to investigate expert's perceptions of fall risk for older adults with cancer. Interview questions were guided by the International Classification of Functioning and Disability (ICF) constructs and the Cancer Aging Research Group's model of fall risk factors. Themes were identified deductively from interview transcriptions. Transcripts were coded using Nvivo software. RESULTS: Ten multidisciplinary experts participated (n = 5 clinical, n = 5 research). Two themes in fall risk factors emerged from interview data: 1) cancer-specific factors aligned with each ICF construct: body function and structures (BF&S), activity and participation (A&P), personal and environmental factors; and 2) a cycle among factors. Experts described that treatment-related limitations in A&P produced or exacerbated impairments in BF&S (physical and mental), leading to falls and further limitations in A&P. Personal and environmental factors influencing this cycle included: cancer-related distress, social support, and perceptions of aging and treatment. CONCLUSION: Experts identified a cycle among cancer-specific fall risk factors for older adults and emphasized the importance of a "holistic" view of the patient to evaluate fall risk. Cancer-related distress, social support and expectations of aging and treatment may influence the cycle between risk factors, with potential negative or protective effects. Future prospective, longitudinal implementation of geriatric assessments and analysis of data may inform risk factors and relationships among factors. Patient interviews could further inform the understanding of fall risk for older adults with cancer.

Embracing the complexity: Older adults with cancer-related cognitive decline-A Young International Society of Geriatric Oncology position paper.

Cancer-related cognitive decline (CRCD) may have particularly significant consequences for older adults, impacting their functional and physical abilities, level of independence, ability to make decisions, treatment adherence, overall quality of life, and ultimately survival. In honor of Dr. Hurria's work we explore and examine multiple types of screening, assessment and non-pharmacologic treatments for CRCD. We then suggest future research and clinical practice questions to holistically appreciate the complexity of older adults with cancer's experiences and fully integrate the team-based approach to best serve this population.

Community-based exercise programs for cancer survivors: a scoping review of practice-based evidence.

PURPOSE: Based on randomized controlled trials, exercise is an efficacious strategy to improve quality of life (QOL) among cancer survivors. However, the effectiveness of exercise programs to improve QOL in real-world settings is unknown, as are factors related to external validity. This hinders dissemination and scalability. This scoping review synthesized published research on community-based exercise programs for cancer survivors and reported on the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM). METHODS: A systematic literature search identified community-based exercise programs for adult cancer survivors (1980-March 2018), that met the following inclusion criteria: at least one face-to-face exercise session, the primary aim of program evaluation (i.e., feasibility/effectiveness), and pre/post measure of QOL. Data were coded using the RE-AIM framework. The effect size was calculated for overall QOL. RESULTS: Electronic database search yielded 553 articles; 31 studies describing unique programs were included for review. All studies described at least one element of implementation and most (80.6%) reported a significant (p < .05) improvement in at least one subscale, or total QOL. Few studies reported on indicators of reach (16.1%), adoption (6.5%), individual (16.1%), or system-level maintenance (32.3%). CONCLUSIONS: Community-based exercise programs are effective for improving QOL in adult cancer survivors. Recommendations are provided to improve reporting across RE-AIM dimensions, which is an important step to enhance the scalability of programs and thus, the potential for exercise to be fully integrated into system-level standard care for cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: Community-based exercise programs are a resource to improve QOL for adult cancer survivors.

Older Adults with Cancer: A Randomized Controlled Trial of Occupational and Physical Therapy.

OBJECTIVES: The impact of occupational therapy (OT) and physical therapy (PT) on functional outcomes in older adults with cancer is unknown. DESIGN: Two-arm single-institution randomized controlled trial of outpatient OT/PT. SETTING: Comprehensive cancer center with two off-site OT/PT clinics. PARTICIPANTS: We recruited adults 65 years and older with a recent diagnosis or recurrence of cancer within 5 years, with at least one functional limitation as identified by a geriatric assessment. Participants were randomized to OT/PT or usual care. INTERVENTION: Rehabilitation consisted of individualized OT and PT that addressed functional activities and strength/endurance needs. MEASUREMENTS: Primary outcome was functional status as measured by the Nottingham Extended Activities of Daily Living scale. Secondary outcomes were Patient-Reported Outcomes Measurement Information System-Global Mental Health (GMH) and Global Physical Health (GPH), ability to participate in Social Roles (SR), physical function, and activity expectations and self-efficacy (Possibilities for Activity Scale [PActS]). RESULTS: Among those recruited (N = 63), only 45 patients (71%) were evaluable due to loss of follow-up and/or nonreceipt of intervention. The median age was 74 years; 53% were female, and 91% were white. Overall, 30% patients had hematologic malignancies, 30% breast cancer, and 16% colorectal cancers. A total of 65% were in active treatment; 49% had stage 3 or 4 disease. At follow-up, both OT/PT (P = .02) and usual care (P = .03) groups experienced a decline in functional status. PActS scores between groups (P = .04) was significantly improved in the intervention group. GMH and SR met criteria for minimally important clinical difference favoring the intervention, but not statistical significance. Several barriers were noted in the implementation of the intervention program: recruitment, concerns about cost, distance, scheduling, and limited treatment provided. CONCLUSION: OT/PT may positively influence activity expectations and self-efficacy. Future research needs to address significant barriers to implementation to increase use of OT/PT services and access to quality care. J Am Geriatr Soc 67:953-960, 2019.

Effect of Group Dynamics-Based Exercise Versus Personal Training in Breast Cancer Survivors.

OBJECTIVES: To determine the feasibility and preliminary effectiveness of a group dynamics-based exercise intervention versus a personal training intervention for increasing physical activity (PA), physical fitness, and quality of life (QOL) in post-treatment breast cancer survivors. SAMPLE & SETTING: 26 women with stage I or II breast cancer who attended intervention activities at a local academic institution. METHODS & VRIABLES: Participants were randomly assigned to receive an eight-week intervention in either a group dynamics-based exercise or a personal training setting. Both intervention arms received supervised exercise twice per week, as well as PA education and discussion sessions. RESULTS: Significant increases were noted in both intervention arms for vigorous PA, chest press, and leg press. Increases in overall QOL and total PA were significant only in the group dynamics-based exercise intervention arm. IMPLICATIONS FOR NURSING: The group dynamics-based exercise intervention produced similar improvements in PA and physical fitness compared to the personal training intervention, and it may have facilitated greater improvements in overall QOL.