The Prehabilitation Radiotherapy Exercise, smoking Habit cessation and Balanced diet Study (PREHABS) protocol to explore the feasibility of embedding behavioural modifications into the clinical pathway for patients undergoing radical radiotherapy for lung cancer.

Patients with curable non-surgical lung cancer are often current smokers, have co-existing medical comorbidities and are treated with curative radiotherapy. To maximise the benefits of modern radiotherapy, there is an urgent need to optimise the patient's health to improve survival and quality of life. METHODS AND ANALYSIS: The Yorkshire Cancer Research-funded Prehabilitation Radiotherapy Exercise, smoking Habit cessation and Balanced diet Study (PREHABS) (L426) is a single-centre prospective feasibility study to assess embedding behavioural changes into the radical radiotherapy pathway of patients with lung cancer. Feasibility will be assessed by measuring acceptability, demand and implementation. The duration of the study is 24 months. PREHABS has two workstreams: the intervention study and the theory of change (ToC) study.Intervention study: PREHABS will commence at the R-IDEAL phase 2 trial (exploratory) based on existing evidence and includes support for smoking cessation, increasing activity and dietary well-being. Patients undergoing radical radiotherapy for lung cancer will be recruited from the oncology department at Leeds Teaching Hospitals NHS Trust (LTHT). ToC study: to maximise the acceptability and adherence to the PREHABS, we will use a ToC approach to qualitatively explore the key barriers and enablers of implementing a tailored programme of 'prehabilitation'. The PREHABS ToC study participants will be recruited from patients with lung cancer undergoing radical radiotherapy and staff from the LTHT oncology department. ANALYSIS: The primary endpoint analysis will report the number of participants and adherence to the study interventions. Secondary endpoints include continued engagement with study interventions post-treatment. The analysis will focus on descriptive statistics. Thematic analysis of the qualitative data from the ToC study will identify consensus on intervention optimisation and delivery. ETHICS AND DISSEMINATION: On 12 May 2021, the Cambridge East Ethics Committee granted ethical approval (21/EE/0048). The study is registered in the National Institute for Health and Care Research (NIHR) portfolio. The results will be disseminated through publication in peer-reviewed scientific journals and presented at conferences. TRIAL REGISTRATION NUMBER: NIHR portfolio 48420.

Physical activity service provision in hospice care: A national mixed-methods study.

BACKGROUND: Physical activity (PA) interventions help people with advanced incurable diseases to manage symptoms and improve their quality of life. However, little is known about the extent to which PA is currently delivered in hospice care in England. OBJECTIVES: To determine the extent of and intervention features of PA service provision in hospice care in England alongside barriers and facilitators to their delivery. METHODS: An embedded mixed-methods design using (1) a nationwide online survey of 70 adult hospices in England and (2) focus groups and individual interviews with health professionals from 18 hospices. Analysis of the data involved applying descriptive statistics to the numeric items and thematic analysis to the open-ended questions. Quantitative and qualitative data were collected and analyzed separately. RESULTS: The majority of responding hospices (n = 47/70, 67%) promoted PA in routine care. Sessions were most often delivered by a physiotherapist (n = 40/47, 85%) using a personalized approach (n = 41/47, 87%) and included resistance/thera bands, Tai Chi/Chi Qong, circuit exercises, and yoga. The following qualitative findings were revealed: (1) variation among hospices in their capacity to deliver PA, (2) a desire to embed a hospice culture of PA, and (3) a need for an organizational commitment to PA service provision. SIGNIFICANCE OF RESULTS: While many hospices in England deliver PA, there is considerable variation in its delivery across sites. Funding and policy action may be needed to support hospices to initiate or scale up services and address inequity in access to high-quality interventions.

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients: a randomised controlled trial (The EMPOWER Trial).

BACKGROUND: The EMPOWER trial aimed to assess the effects of a 9-week exercise prehabilitation programme on physical fitness compared with a usual care control group. Secondary aims were to investigate the effect of (1) the exercise prehabilitation programme on psychological health; and (2) neoadjuvant chemoradiotherapy (NCRT) on physical fitness and psychological health. METHODS: Between October 2013 and December 2016, adults with locally advanced rectal cancer undergoing standardised NCRT and surgery were recruited to a multi-centre trial. Patients underwent cardiopulmonary exercise testing (CPET) and completed HRQoL questionnaires (EORTC-QLQ-C30 and EQ-5D-5L) pre-NCRT and post-NCRT (week 0/baseline). At week 0, patients were randomised to exercise prehabilitation or usual care (no intervention). CPET and HRQoL questionnaires were assessed at week 0, 3, 6 and 9, whilst semi-structured interviews were assessed at week 0 and week 9. Changes in oxygen uptake at anaerobic threshold (VO2 at AT (ml kg-1 min-1)) between groups were compared using linear mixed modelling. RESULTS: Thirty-eight patients were recruited, mean age 64 (10.4) years. Of the 38 patients, 33 were randomised: 16 to usual care and 17 to exercise prehabilitation (26 males and 7 females). Exercise prehabilitation significantly improved VO2 at AT at week 9 compared to the usual care. The change from baseline to week 9, when adjusted for baseline, between the randomised groups was + 2.9 ml kg -1 min -1; (95% CI 0.8 to 5.1), p = 0.011. CONCLUSION: A 9-week exercise prehabilitation programme significantly improved fitness following NCRT. These findings have informed the WesFit trial (NCT03509428) which is investigating the effects of community-based multimodal prehabilitation before cancer surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT01914068 . Registered 1 August 2013.

"I didn't want to do it on my own": A qualitative study of women's perceptions of facilitating and risk factors for weight control on a UK commercial community program.

Overweight and obesity remain serious public health concerns. Outcomes from community based commercial weight management programmes vary, relapse is common and drop out is high. Outcomes could be improved by better understanding experiences on these programmes. The aim of our study was to generate accounts of people's experience on a commercial weight-management program to identify what experiences were perceived as facilitating, and what posed risks, to programme effectiveness and compliance. We conducted individual, semi-structured interviews with eighteen Caucasian women (mean age 45.4y) who were members of nation-wide UK commercial, fee-paying, community weight management programme. Interview data was analysed via framework analysis. Participants' experiences indicated that the programme helped by triggering several intra- and interpersonal processes that catalysed change across psychological, physiological, dietary and behavioural areas of their life. Risks to program adherence and effectiveness spanned well-known risks such as self-regulation fatigue and the difficulty of recovering from negative self-criticism, as well as new factors such as the confusing nature of weight change, the relatively powerful impact of everyday events, and the difficulty in getting the balance right between personalised support vs. intrusion. The complexity of reported experiences challenges the linear, predictive pathways of change proposed by many health behaviour models of weight management. To improve effectiveness, programmes need to go well beyond behavioural and dietary support. It is recommended that community, commercial programmes educate people about the physiological and psychological tensions they will encounter, why people lose weight at different rates, the likelihood of weight relapse and strategies to manage these, including evidence-based support for managing self-criticism.

Physical Activity in Hospice Care: A Social Ecological Perspective to Inform Policy and Practice.

Purpose: Physical activity (PA) is increasingly being used in hospice care as a rehabilitation strategy to help patients manage symptoms and improve quality of life. However, little is known about how to design and deliver interventions that promote uptake and maintenance of PA in this population. Single-level approaches (i.e., psychological models) have primarily been used to study factors that influence PA engagement among patients with advanced, incurable disease and therefore offer a limited perspective on strategies that target changes beyond the individual level. This study explored perspectives on factors perceived important for influencing PA participation in hospice care using a social-ecological framework. Method: Patients (n = 27) and health providers (n = 5) from multiple hospices (n = 5) across the UK were involved in this study. Data were collected using focus group and individual semi-structured interviews and analyzed using a thematic framework approach. Results: Eight main themes were perceived to be important for influencing PA engagement at the individual, interpersonal, physical environment, community, and policy levels including: (1) PA as therapy; (2) apprehension about PA-induced harm; (3) group-based PA with peers; (4) supervised PA sessions; (5) limited facilities and access; (6) patient-centered approach; (7) lack of a strong PA culture and; (8) absence of a policy and guidance for PA provision. Conclusion: Hospice-based PA interventions that target multiple levels simultaneously may be more effective at successfully changing and sustaining patients' PA behavior. Study findings provide evidence-based recommendations that may facilitate the effective delivery of PA interventions in hospice care.

Cycling Through Cancer: Exploring Childhood Cancer Survivors' Experiences of Well- and Ill-Being.

The benefits of informal physical activity during recovery from childhood cancer have rarely been investigated. This study adopted a multiple case study approach to explore the impact of recreational cycling on childhood cancer survivors' experiences of well- and ill-being. Three semistructured interviews were conducted over a 3-month period with four survivors to explore their experiences of physical, psychological, and social well- and ill-being. Within-case analysis followed by cross-case analysis identified three themes that captured their well- and ill-being experiences with recreational cycling and cancer: (a) cultivating feelings and emotions, (b) experiencing physical changes, and (c) encountering positive and negative social interactions. The results from this study show that recreational cycling may be a useful adjunct to conventional treatments for the self-management of multiple domains of well- and ill-being during recovery from childhood cancer.

Physical Activity and Quality of Life in Cancer Survivors: A Meta-Synthesis of Qualitative Research.

Qualitative research on the impact of physical activity on quality of life (QoL) in adults diagnosed with cancer is accumulating. However, the field of physical activity and cancer survivorship lack a synthesis of this research to reliably understand the implications for future research and practice. The aim of this meta-synthesis was to identify, appraise, and synthesize qualitative research on cancer survivors' perspectives of the impact of physical activity on their QoL. Seven electronic databases were searched for original studies published in English, and reference lists of relevant studies were hand-searched to identify additional studies. Forty studies met eligibility criteria and were included in this meta-synthesis. Study characteristics and major findings were extracted, and findings were summarized, compared, and synthesized. Themes identified in this review revealed that physical activity positively impacted four dimensions of cancer survivors' QoL: physical (e.g., managing the physical consequences of cancer and its treatment), psychological (e.g., evoking positive self-perceptions), social (e.g., feeling understood by others), and spiritual (e.g., redefining life purpose). This meta-synthesis corroborates conclusions from reviews of quantitative research and illustrates that physical activity can be used to improve QoL in adult cancer survivors, regardless of diagnosis (i.e., stage, cancer type) and treatment status. It also provides detailed insight into specific aspects within each dimension of QoL impacted by physical activity from cancer survivors' perspectives, which is important for understanding the meaning and utility of physical activity for them. However, more research is needed to further develop the qualitative evidence base in order to better understand how physical activity impacts on QoL experiences in men, young adults, and adults diagnosed with less common types of cancer at different points along cancer trajectory (i.e., diagnosis, treatment, post-treatment, palliation).

The effects of exercise on pain, fatigue, insomnia, and health perceptions in patients with operable advanced stage rectal cancer prior to surgery: a pilot trial.

BACKGROUND: Promoting quality of life (QoL) is a key priority in cancer care. We investigated the hypothesis that, in comparison to usual care, exercise post-neoadjuvant chemoradiation therapy/prior to surgical resection will reduce pain, fatigue, and insomnia, and will improve physical and mental health perceptions in patients with locally advanced stage rectal cancer. METHODS: In this non-randomized controlled pilot trial, patients in the supervised exercise group (EG; M age = 64 years; 64% male) and in the control group (CG; M age = 72 years; 69% male) completed the European Organization for Research and Treatment of Cancer core Quality of Life questionnaire and the RAND 36-Item Health Survey three times: pre-neoadjuvant chemoradiation therapy (Time 1; n EC = 24; n CG = 11), post-neoadjuvant chemoradiation therapy/pre-exercise intervention (Time 2; n EC = 23; n CG = 10), and post-exercise intervention (Time 3; n EC = 22; n CG = 10). The 6-week exercise intervention was delivered in hospital and comprised of interval aerobic training. Patients trained in pairs three times per week for 30 to 40 min. Data were analyzed by Mann-Whitney tests and by Wilcoxon matched-pairs signed-rank tests. RESULTS: No significant between-group differences in changes were found for any of the outcomes. In both groups, fatigue levels decreased and physical health perceptions increased from pre- to post-exercise intervention. Pain levels also decreased from pre- to post-exercise intervention, albeit not significantly. CONCLUSIONS: The findings from this study can be used to guide a more definitive trial as they provide preliminary evidence regarding the potential effects of pre-operative exercise on self-reported pain, fatigue, insomnia, and health perceptions in patients with locally advanced rectal cancer. TRIAL REGISTRATION: This study has been registered with clinicaltrials.gov (NCT01325909; March 29, 2011).

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients (The EMPOWER Trial): study protocol for a randomised controlled trial.

BACKGROUND: The standard treatment pathway for locally advanced rectal cancer is neoadjuvant chemoradiotherapy (CRT) followed by surgery. Neoadjuvant CRT has been shown to decrease physical fitness, and this decrease is associated with increased post-operative morbidity. Exercise training can stimulate skeletal muscle adaptations such as increased mitochondrial content and improved oxygen uptake capacity, both of which are contributors to physical fitness. The aims of the EMPOWER trial are to assess the effects of neoadjuvant CRT and an in-hospital exercise training programme on physical fitness, health-related quality of life (HRQoL), and physical activity levels, as well as post-operative morbidity and cancer staging. METHODS/DESIGN: The EMPOWER Trial is a randomised controlled trial with a planned recruitment of 46 patients with locally advanced rectal cancer and who are undergoing neoadjuvant CRT and surgery. Following completion of the neoadjuvant CRT (week 0) prior to surgery, patients are randomised to an in-hospital exercise training programme (aerobic interval training for 6 to 9 weeks) or a usual care control group (usual care and no formal exercise training). The primary endpoint is oxygen uptake at lactate threshold ([Formula: see text] at [Formula: see text]) measured using cardiopulmonary exercise testing assessed over several time points throughout the study. Secondary endpoints include HRQoL, assessed using semi-structured interviews and questionnaires, and physical activity levels assessed using activity monitors. Exploratory endpoints include post-operative morbidity, assessed using the Post-Operative Morbidity Survey (POMS), and cancer staging, assessed by using magnetic resonance tumour regression grading. DISCUSSION: The EMPOWER trial is the first randomised controlled trial comparing an in-hospital exercise training group with a usual care control group in patients with locally advanced rectal cancer. This trial will allow us to determine whether exercise training following neoadjuvant CRT can improve physical fitness and activity levels, as well as other important clinical outcome measures such as HRQoL and post-operative morbidity. These results will aid the design of a large, multi-centre trial to determine whether an increase in physical fitness improves clinically relevant post-operative outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT01914068 (received: 7 June 2013). SPONSOR: University Hospital Southampton NHS Foundation Trust.

Patients' perceptions of quality of life during active treatment for locally advanced rectal cancer: the importance of preoperative exercise.

PURPOSE: The purpose of this longitudinal study was to explore advanced rectal cancer patients' perceptions of quality of life (QoL) during participation in a pre-surgery structured exercise program. METHODS: Patients (n = 10) participated in repeated semi-structured in-depth interviews which covered four broad QoL domains (i.e., physical, psychological, social, and spiritual well-being). Patients' personal accounts of QoL were explored prior to (0 weeks), midway (3 weeks), and at completion (6 weeks) of the program. Data were analyzed using strategies grounded in a phenomenological approach. RESULTS: Participation in the program facilitated positive changes in QoL over time by (1) fostering a greater sense of vitality, (2) cultivating a positive attitude, (3) enhancing social connections, and (4) fostering a strong sense of purpose in life for these patients. CONCLUSIONS: Based on these data, preoperative exercise programs can be effective in promoting QoL among patients diagnosed and treated for locally advanced rectal cancer during a particularly difficult time in the cancer trajectory. Additional research is needed to develop and evaluate implementation strategies to facilitate the delivery of preoperative exercise programs as part of routine care in this population.

A qualitative exploration of barriers and motivators to physical activity participation in women treated for breast cancer.

PURPOSE: The adoption and maintenance of a physically active lifestyle among women after breast cancer is an important priority for public health and rehabilitation science. The purpose of this qualitative study was to explore breast cancer survivors' perceptions of the factors influencing their ability to maintain a self-directed physical activity program. METHOD: Nine women participated in semi-structured, in-depth interviews. Data were coded into perceived barriers and motivators to maintenance of physical activity using thematic analysis. RESULTS: Women identified a range of physical (e.g. cancer-related physical symptoms), environmental/organizational (e.g. bad weather, lack of equipment/facilities, lack of knowledge, time constraints) and psychosocial (e.g. lack of motivation, low social support, low confidence/skill) barriers. They also identified perceived physical (e.g. weight management, health improvement or maintenance, increase energy) and psychosocial (e.g. improve body image, experience enjoyment, social support, positive emotions) motivators. CONCLUSIONS: These findings are consistent with research on barriers and motivators to physical activity initiation, and can be used to develop self-directed physical activity programs that target active breast cancer survivors to sustain regular engagement. Furthermore, the barriers and motivators identified represent key variables for further investigation. IMPLICATIONS FOR REHABILITATION: The present study identifies a number of perceived physical, psychosocial and organizational/environmental barriers to naturally occurring physical activity participation among active breast cancer survivors that should be addressed to ensure they maintain a physically active lifestyle This study also provides evidence that comprehensive approaches that address physical and psychosocial motivators to physical activity should be developed to assist women with a history of breast cancer maintain their physical activity levels.

The benefits of being self-determined in promoting physical activity and affective well-being among women recently treated for breast cancer.

PURPOSE: In this study, changes in motivational regulations in women following treatment for breast cancer were described. Changes in motivational regulations as predictors of subsequent change in light and moderate-to-vigorous physical activity (PA) and affect were also examined. METHODS: Women [n = 150; M(age) = 54.41 (SD = 10.87) years] completed self-report questionnaires and wore an accelerometer for 7 days at Time 1 [M = 3.94 (SD = 3.08) months following primary treatment], as well as 3 (Time 2) and 6 (Time 3) months later. Data were analyzed using repeated-measures analysis of variance and path analysis using residual change scores. RESULTS: Identified regulation and self-determined motivation (i.e., combined intrinsic motivation and identified regulation) scores decreased over time (p < 0.05). In the path model [χ(2)(4) = 5.66, p = 0.22, root mean square error of approximation = 0.05 (90% CI: 0.0; 0.15), comparative fit index = 0.99, standardized root mean square of the residuals = 0.03], ΔTime(1-2) in external regulation was associated with ΔTime(2-3) in positive affect (ß = -0.16), ΔTime(1-2) in introjected (ß = 0.25) and amotivation (ß = 0.19) were related to ΔTime(2-3) in negative affect, and ΔTime(1-2) in self-determined motivation was related to ΔTime(2-3) in positive affect (ß = 0.40) and moderate-to-vigorous PA (ß = 0.21). CONCLUSIONS: Changes in motivational regulations were related to changes in PA and affect in the aftermath of breast cancer. Given the benefits of self-determined motivation, additional research is needed to develop and test interventions aimed at enhancing this type of motivation.

Surviving breast cancer: women's experiences with their changed bodies.

In this study, we explored women's experiences with their bodies following treatment for breast cancer. Eleven women who had been treated for the disease (M(time since treatment)=4.45 years) were interviewed. Data were collected and analyzed using interpretative phenomenological analysis (Smith et al., 2009). Four main themes emerged from the data: changing visibly and invisibly; experiencing intense thoughts and emotions; meaning of the body: a vehicle of health, well-being, and social expression; and managing and dealing with physical changes. Overall, the women experienced various physical changes that shaped, mostly in a negative way, their perceptions, thoughts, attitudes, feelings, and beliefs about their bodies. The women described attempts to make positive lifestyle behavior choices (e.g., diet, participate in physical activity), and used other strategies (e.g., wigs, make-up, clothes) to manage their appearances and restore positive body-related experiences. Based on these findings, it is important to be cognizant of women's body image concerns following breast cancer given the poignant and lasting effects they can have on their psychosocial and emotional well-being.

Pain, movement, and mind: does physical activity mediate the relationship between pain and mental health among survivors of breast cancer?

OBJECTIVES: This study examined the relationship between pain and mental health outcomes of depression and affect among survivors of breast cancer. The mediating role of physical activity was also tested. METHODS: Survivors of breast cancer (N=145) completed self-report measures of pain symptoms at baseline, wore an accelerometer for 7 days, and reported levels of depression symptoms and negative and positive affect 3 months later. Hierarchical linear regression analyses, controlling for personal and cancer-related demographics, were used to test the association between pain symptoms and each mental health outcome, as well as the mediation effect of physical activity. RESULTS: Pain positively predicted depression symptoms [F(6,139)=4.31, P<0.01, R=0.15] and negative affect [F(5,140)=4.17, P<0.01, R=0.13], and negatively predicted positive affect [F(6,139)=2.12, P=0.03, R=0.08]. Physical activity was a significant (P<0.01) partial mediator of the relationship between pain and depression and between pain and positive affect. DISCUSSION: Participation in physical activity is one pathway through which pain influences mental health. Efforts are needed to help survivors of breast cancer manage pain symptoms and increase their level of physical activity to help improve mental health.

Passion in breast cancer survivors: examining links to emotional well-being.

This study (1) identified the activities that breast cancer survivors report as passionate; (2) examined whether levels of passion differed based on the types of passionate activities reported and; (3) examined the association between harmonious and obsessive passion and emotional well-being. Early post-treatment breast cancer survivors (N = 177) reported passionate physical activities as most prevalent, and reported higher harmonious passion scores compared to women reporting relaxing and social leisure activities. Harmonious passion was associated with higher positive affect and lower cancer worry. Obsessive passion was linked to higher negative affect, cancer worry, and posttraumatic growth. Passion is important for enhanced well-being.