Personalised exercise rehabilitation in cancer survivorship: the percs triage and referral system study protocol.

BACKGROUND: To effectively embed exercise rehabilitation in cancer survivorship care, a co-ordinated system of acute and community exercise rehabilitation services, forming a stepped model of care, is recommended. Patients can be directed to the exercise rehabilitation service which best meets their needs through a system of assessment, triage and referral. Triage and referral systems are not yet widely applied in cancer survivorship practice and need to be evaluated in real-world contexts. The PERCS (Personalised Exercise Rehabilitation in Cancer Survivorship) study aims to evaluate the real-world application of an exercise rehabilitation triage and referral system in cancer survivors treated during the COVID-19 pandemic. Secondary aims are to evaluate change in physical and psychosocial outcomes, and to qualitatively evaluate the impact of the system and patient experiences, at three months after application of the triage and referral system. METHODS: This study will assess the implementation of an exercise rehabilitation triage and referral system within the context of a physiotherapy-led cancer rehabilitation clinic for cancer survivors who received cancer treatment during the COVID-19 pandemic. The PERCS triage and referral system supports decision making in exercise rehabilitation referral by recommending one of three pathways: independent exercise; fitness professional referral; or health professional referral. Up to 100 adult cancer survivors treated during the COVID-19 pandemic who have completed treatment and have no signs of active disease will be recruited. We will assess participants' physical and psychosocial wellbeing and evaluate whether medical clearance for exercise is needed. Participants will then be triaged to a referral pathway and an exercise recommendation will be collaboratively decided. Reassessment will be after 12 weeks. Primary outcomes are implementation-related, guided by the RE-AIM framework. Secondary outcomes include physical function, psychosocial wellbeing and exercise levels. Qualitative analysis of semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) will provide insights on implementation and system impact. DISCUSSION: The PERCS study will investigate the real-world application of a cancer rehabilitation triage and referral system. This will provide proof of concept evidence for this triage approach and important insights on the implementation of a triage system in a specialist cancer centre. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov, registration number: NCT05615285, date registered: 21st October 2022.

Quality of life, adherence to voice rehabilitation therapy and psychological variables in patients with head and neck cancer / Calidad de vida, adherencia al tratamiento de rehabilitación de voz y variables psicológicas en pacientes con cáncer de cabeza y cuello

Introduction: Voice problems can affect quality of life (QoL), other psychological aspects, and the adequate adherence to voice rehabilitation therapy. Objective: To determine the association between QoL and treatment adherence (TA) to voice rehabilitation with symptoms of anxiety, depression, and coping strategies. Method: A longitudinal study was conducted with 97 participants with head and neck cancer (H&N) who were attending voice rehabilitation therapy. Instruments: EORTC QLQ-C30 and QLQ-H&N35, Treatment Adherence Checklist, Cancer Coping Questionnaire and HADS. Results: The mean overall QoL was 83.33, and mean TA was 8.80. Lower overall QoL and emotional functioning scores, as well as higher dry mouth scores were associated with higher levels of anxiety. Greater problems with social contact and lower TA were associated to higher depression scores. Conclusion: Consistent with the literature, TA and QoL were associated to depression and QoL was also correlated to anxiety. These results are among the first to explore such aspects in Latino patients and emphasize the importance of multidisciplinary care for H&N cancer patients in voice rehabilitation therapy, given that during their treatment they may encounter psychological barriers that could hinder their progress in voice quality and QoL.(AU)

Introducción: Los problemas de la voz pueden afectar la calidad de vida (CV) y otros aspectos psicológicos, así como la adecuada adherencia a la terapia de rehabilitación de voz. Objetivo: Determinar la relación entre la CV y la adherencia al tratamiento (AT) de rehabilitación de voz con síntomas de ansiedad, depresión y estrategias de afrontamiento. Método: Se realizó un estudio longitudinal en 97 participantes con cáncer de cabeza y cuello (CyC) que asistían a terapia de rehabilitación de voz. Instrumentos: EORTC QLQ-C30 y QLQ-H&N35, Lista de Verificación de Adherencia al Tratamiento, la Escala de Afrontamiento al Cáncer y la HADS. Resultados: La CV global promedio fue de 83.33 y el puntaje promedio de AT fue de 8.80. La calidad de vida global, la función emocional y boca seca se asociaron con la ansiedad. La dimensión de la CV contacto social y la AT tuvieron relación con la depresión. Conclusiones: Consistente con la literatura la AT y la CV tuvieron relación con la depresión y solo la CV se relacionó con la ansiedad. Los resultados presentados son de los primeros en explorar estos aspectos en pacientes latinos y enfatizan la importancia de la atención multidisciplinaria a pacientes con cáncer de CyC en terapia de rehabilitación de voz, dado que en el curso de sus tratamientos pueden encontrar barreras psicológicas que obstaculicen la mejora en la calidad de la voz y la CV.(AU)

Roadmap for Connecting Cancer Rehabilitation With Survivorship to Improve Patient Outcomes and Clinical Efficiency.

ABSTRACT: An evolved model of comprehensive cancer care is needed that begins at cancer diagnosis to proactively manage cancer treatment toxicities and optimize patient health, function, and well-being. Building new care models requires connecting oncology, primary care, and specialized clinicians from many disciplines including cancer rehabilitation. Having a vision for an evolved standard of comprehensive cancer care is a requirement, but it is not enough to bring an innovative clinical program to life and sustain it over the long term. To inform the development of new clinical programs, two example programs are presented that successfully integrate cancer rehabilitation services along with details of a three-step process these programs used to facilitate their success and build robust business models that ensure their sustainability. Following the roadmap for growth presented here, gaining input from stakeholders and ensuring their buy-in, leveraging existing programmatic priorities, as well as developing a strategic growth plan can help clinical innovators ensure that new programs anticipate and continually meet the needs of oncology, primary care, subspecialty care, and programs, while addressing the business needs of administrators and improving the experience for patients.

Dropout from exercise trials among cancer survivors-An individual patient data meta-analysis from the POLARIS study.

INTRODUCTION: The number of randomized controlled trials (RCTs) investigating the effects of exercise among cancer survivors has increased in recent years; however, participants dropping out of the trials are rarely described. The objective of the present study was to assess which combinations of participant and exercise program characteristics were associated with dropout from the exercise arms of RCTs among cancer survivors. METHODS: This study used data collected in the Predicting OptimaL cAncer RehabIlitation and Supportive care (POLARIS) study, an international database of RCTs investigating the effects of exercise among cancer survivors. Thirty-four exercise trials, with a total of 2467 patients without metastatic disease randomized to an exercise arm were included. Harmonized studies included a pre and a posttest, and participants were classified as dropouts when missing all assessments at the post-intervention test. Subgroups were identified with a conditional inference tree. RESULTS: Overall, 9.6% of the participants dropped out. Five subgroups were identified in the conditional inference tree based on four significant associations with dropout. Most dropout was observed for participants with BMI >28.4 kg/m2 , performing supervised resistance or unsupervised mixed exercise (19.8% dropout) or had low-medium education and performed aerobic or supervised mixed exercise (13.5%). The lowest dropout was found for participants with BMI >28.4 kg/m2 and high education performing aerobic or supervised mixed exercise (5.1%), and participants with BMI ≤28.4 kg/m2 exercising during (5.2%) or post (9.5%) treatment. CONCLUSIONS: There are several systematic differences between cancer survivors completing and dropping out from exercise trials, possibly affecting the external validity of exercise effects.

Inpatient Rehabilitation of Hematopoietic Stem Cell Transplant Patients: Managing Challenging Impairments and Medical Fragility.

ABSTRACT: Hematopoietic stem cell transplants play an important role in the treatment of cancer, particularly hematologic malignancies. These patients can encounter functional impairments unique to hematopoietic stem cell transplant, including deconditioning, cancer-related fatigue, steroid myopathy, graft versus host disease, and capillary leak syndrome. Medical fragility and increased risk of infection may make rehabilitation challenging on the acute care and postacute care settings. Patients admitted to acute inpatient rehabilitation experience a high rate of transfer to the primary acute service and high rate of mortality after transfer back. Physical medicine and rehabilitation physicians can use a number of strategies to mitigate these patients' risk of medical complications including evidence-based predictive models to assist with postacute rehabilitation triage, physiatry-led consult-based rehabilitation, and oncology hospitalist comanagement on inpatient rehabilitation.

Promoting physical activity among cancer survivors: an umbrella review of systematic reviews.

PURPOSE: Exercise is the core element of rehabilitation for cancer patients. However, most of the patients' exercise levels failed to meet the indicators recommended by the guidelines or even decreased. Therefore, this umbrella review aims to provide an overview of review articles addressing the evidence of interventions to promote physical activity behavior change and increase physical activity among cancer patients. METHODS: We searched nine databases from inception to 12 May 2022 to obtain systematic reviews and meta-analyses of interventions to promote physical activity among cancer patients. The AMSTAR-2 was used for the quality assessment. RESULTS: Twenty-six individual systematic reviews including 13 studies performed meta-analyses. A total of 16 studies' designs were all in randomized controlled trial. Most reviews included studies that were mainly delivered in home settings. The most frequent and mean duration of the interventions was 12 weeks. Interventions mainly included electronic, wearable health technology-based, behavior change techniques (BCTs), and theory-based strategies. CONCLUSIONS: Electronic, wearable health technology-based, BCTs, and theory-based interventions were effective and feasible in promoting physical activity in cancer survivors. Clinical practitioners should take corresponding intervention measures according to the characteristics of patients in different groups. IMPLICATIONS FOR CANCER SURVIVORS: Future research may benefit cancer survivors by more comprehensively applying electronic, wearable health technology-based, BCTs, and theory-based interventions.

Participation in and Satisfaction with a Community-Based Physical Activity Program Among Hispanic Cancer Survivors.

The objective of this study was to explore the experience of Hispanic cancer survivors participating in Active Living After Cancer (ALAC), a community-based physical activity program. We analyzed participation and satisfaction data from 250 participants who completed the program from 2017 to 2020 (55% Hispanic, 28% Black, 14% non-Hispanic White). Using a hybrid coding approach, open-text survey comments responses from Hispanic participants (n = 138) were qualitatively analyzed and key themes developed to better contextualize the quantitative results. Quantitative analysis revealed that Hispanic participants attended an average of 9.44 out of 12 sessions. There were no differences in attendance by race/ethnicity; however, Hispanic participants reported significantly higher overall satisfaction ratings than non-Hispanic White participants (4.93 vs 4.65 on a 5-point scale). Open-ended comments indicated that Hispanic ALAC participants experience collective efficacy, self-efficacy, and self-regulation, through observational learning enabled by program facilitation. The ALAC program is highly acceptable and relevant to Hispanic cancer survivors and will inform the continued expansion of other community-based survivorship programs for Hispanic communities throughout Texas.

Multimodal Physical Exercise and Functional Rehabilitation Program in Oncological Patients with Cancer-Related Fatigue-A Randomized Clinical Trial.

The increase in life expectancy and survival time implies an increase in the possible side-effects of pharmacological treatments in patients. Cancer-related fatigue is one of these side-effects. The main objective of this study was to evaluate the effects of a multimodal program of physical exercise and functional rehabilitation on asthenia, pain, functional capacity, and quality of life in cancer patients with cancer-related fatigue. METHODS: This was a randomized, parallel-controlled clinical trial, with two arms (experimental and control group), and it was conducted over the course of a year in the Oncology Hospitalization Unit at the University Hospital of Salamanca, Spain. Participants (n = 48) were assessed at three points during the study. The first assessment was prior to hospital discharge, the second assessment was after 15 days, and the final assessment was at one month post-hospital follow-up. The intervention lasted one month. The main variables studied were the dependency levels (Barthel), cancer-related fatigue (FACT-An), health-related quality of life (EuroQoL-5D), functional capacity (SPPB), and kinesiophobia (TSK-F). RESULTS: Sample size (n = 44). Mean age 63.46 ± 12.36 years. Significant differences between control and experimental group participants in Barthel, FACT-An, TSK-F, and SPPB scores at follow-up and final assessment. CONCLUSIONS: There are beneficial effects of a multimodal physical exercise and functional rehabilitation program in improving the autonomy of cancer-related fatigue patients.

Post-acute Care Needs and Benefits of Inpatient Rehabilitation Care for the Oncology Patient.

PURPOSE OF REVIEW: This study aims to assess recent literature published on the post-acute care needs of cancer patients, specifically focusing on the acute inpatient rehabilitation setting. RECENT FINDINGS: The neurologic cancer population appears to be the most studied oncologic population in acute inpatient rehabilitation studies within the past 5 years. This finding is consistent with prior findings from the past several decades. Recent trends in inpatient cancer rehabilitation note a population with lower admission functional status and shorter lengths of stay compared to prior studies. Despite these findings, the percentage discharged to the community remains high. With new treatments yielding improved survival, cancer patients may live longer and risk accumulating more functional impairments. Physicians involved in their care must understand post-acute care needs and work in a multidisciplinary group to best determine post-acute disposition. This decision remains very individualized and should consider both oncologic and functional needs.

Adherence, safety, and satisfaction of a cardio-oncology rehabilitation program framework versus community exercise training for cancer survivors: findings from the CORE trial.

PURPOSE: To assess safety, satisfaction, and overall adherence of a center-based cardiac rehabilitation (CBCR) program for cancer survivors at increased cardiovascular (CV) risk, compared to community-based exercise training (CBET). METHODS: The CORE study was a single-center, prospective, randomized controlled trial enrolling cancer survivors exposed to cardiotoxic cancer treatment and/or with previous CV disease. Participants were randomized to an 8-week CBCR program or CBET, twice a week. Overall feasibility (consent, retention, and completion rates), intervention adherence (percentage of exercise sessions attended), and safety were assessed. Adverse events (AEs) were registered, and participants' satisfaction was measured at the end of the study. RESULTS: Eighty out of 116 potentially eligible individuals were included; consent rate was 72.4%, and 77 (96.2%) started the study (retention rate 100% in CBCR vs 92.5% in CBET); completion rate was 92.5%. Intervention adherence was higher in CBCR (90.3 ± 11.8% vs 68.4 ± 22.1%, p < 0.001). Exercise-related AEs were mainly related to musculoskeletal conditions in both groups (7 in CBCR vs 20 in CBET, p < 0.001), accounting for exercise prescription modification in 47 sessions (18 (3.3%) in CBCR vs 29 (7.2%) in CBET, p = 0.006), none motivating exercise discontinuation. No participants reported major CV events. Overall, the satisfaction with the different aspects of the programs (e.g., expectations, monitoring) was higher in the CBCR. CONCLUSION: This exploratory analysis of the CORE trial suggests that both exercise-based interventions are feasible and safe in this setting. The higher intervention adherence and patient satisfaction in CBCR suggest that this comprehensive approach could be of interest in this population.

Relationship Between Cachexia and the Functional Progress of Patients With Cancer in Inpatient Rehabilitation.

PURPOSE: Although inpatient rehabilitation can improve functional independence in patients with cancer, the role of cachexia in this population is unknown. Our objectives were to:1) Establish prevalence of cachexia in a cohort of cancer patients receiving inpatient rehabilitation and its association with demographic and oncological history.2) Determine the relationship between the presence of cachexia and functional recovery and whether these patients in inpatient rehabilitation have a distinct prognosis. METHODS: This is a retrospective cohort study of 250 patients over 330 admissions to an inpatient rehabilitation facility. Body weight loss threshold and Weight Loss Grading Scale identified patients with and without cachexia. Main outcomes were functional independence measure scores, discharge destination, and 6-mo survival. RESULTS: Prevalence of cachexia in inpatient rehabilitation was 59% using consensus body weight loss criteria, and 77% of cancer patients had a Weight Loss Grading Scale score greater than 0. Patients with and without cachexia had similar motor and cognitive gains, although patients with severe cachexia had more limited functional gains ( P < 0.05) and increased odds of acute care return ( P < 0.01). Patients with a Weight Loss Grading Scale score of 4 had decreased survival at 6 mos ( P < 0.05) compared with noncachectic patients. CONCLUSIONS: These data suggest that there is a relationship between cachexia and recovery for cancer patients that should be further studied in rehabilitation settings.

Rare cancer and return to work: experiences and needs of patients and (health care) professionals.

PURPOSE: Patients with a rare cancer often face delays in their diagnostic and treatment trajectory, which may affect their work. In this study, we explored experiences and needs of: 1) patients with a rare cancer regarding return to work (RTW) and work retention, and 2) (health care) professionals (HCPs) regarding work-related support of patients with a rare cancer, throughout their disease trajectory. METHODS: Semi-structured, in-depth interviews with working-age patients with a rare cancer (n = 16), and HCPs (n = 9) were conducted. During the interviews, a predefined topic list was used. Interviews were transcribed verbatim and analysed by means of thematic analysis. RESULTS: In total, three themes emerged from the interviews: 1) Awareness in patients and HCPs as a first step towards work, 2) Being/becoming an expert is a tough job, and 3) Enhancing employability through early personalized guidance. CONCLUSIONS: Patients with a rare cancer are confronted with uncertainties regarding work, due to an overall lack of knowledge and experience with these types of cancer. Raising awareness among patients, HCPs and employers about rare cancer and its implications, and providing timely individualized, supportive occupational care are required to improve rare cancer patients' ability to work.Implications for rehabilitationRecognizing and paying attention to the work-related consequences of a rare cancer diagnosis and its treatment is essential to facilitate rare cancer patients' occupational rehabilitation process.Multidisciplinary collaboration and involvement of HCPs specialized in rare cancer are required to provide suitable work-related support.A personalized approach is necessary to adequately address rare cancer patients' RTW and work retention needs.

Exercise training as part of multidisciplinary rehabilitation in cancer survivors: an observational study on changes in physical performance and patient-reported outcomes.

PURPOSE: To describe changes in physical performance and patient-reported outcomes in cancer survivors who participated in an exercise program as part of usual-care multidisciplinary rehabilitation and the influence of training adaptations during the coronavirus-19 (COVID-19) pandemic. METHODS: In an observational cohort study, cancer survivors underwent usual-care multidisciplinary rehabilitation including a 10-week exercise program. During the COVID-19 pandemic, the exercise program was adapted with reduced training time and frequency. Mean changes and 95% confidence intervals in physical performance (peak oxygen uptake (VO2peak), peak work rate during a steep ramp test (SRT-WRpeak), 6-min walking distance, muscle strength) and patient-reported outcomes (health-related quality of life, fatigue, anxiety, and depression) were assessed between the start and the end of the exercise program. Linear regression analysis, adjusting for baseline levels of outcomes, was used to investigate differences in changes in outcomes between participants who underwent the original and the adapted program. RESULTS: All outcomes statistically significantly improved over time, regardless of adaptations in the exercise program. VO2peak increased with 9.6% and 7.7% in the original and adapted program, respectively. Significant smaller improvements were observed in SRT-WRpeak (- 3.9%) and upper body muscle strength (- 10.8%) after participation in the adapted compared to the original program. No significant between-group differences were observed for other outcomes. CONCLUSION: Physical performance and patient-reported outcomes statistically and clinically significantly improved in cancer survivors who participated in an exercise program as part of usual-care multidisciplinary rehabilitation. Improvements of performance outcomes were smaller since the training adaptations, though only significant for SRT-WRpeak and upper body strength.

The Role of Exercise Before Cancer Treatment.

OBJECTIVES: We aim to describe on the role of exercise in preparation for cancer treatments (prehabilitation) that include surgery and neoadjuvant or nonsurgical approaches. We discuss the evidence for the role of exercise and provide guidelines to exercise prescription and examples of the structure of prehabilitation exercise programs. DATA SOURCE: We use peer-reviewed articles obtained through PubMed searches with search terms: exercise, oncology, cancer surgery, exercise physiology, respiratory exercises, prehabilitation, and behavior change. CONCLUSION: The emergence of prehabilitation in preparing patients for cancer care has followed a rapidly upward trajectory over the past 20 years. Exercise prehabilitation remains the cornerstone of management, particularly in patients attending for major surgery. Multimodal approaches to supporting patients before cancer treatment are now well accepted and include screening and individualized treatments of functional, nutritional, and psychological impairments. Respiratory training before surgery and the addition of behavior change strategies to improve adherence to interventions and promote improved longer-term outcomes are now included in many prehabilitation programs. For exercise to be an effective treatment in improving fitness and strength, supervised aerobic and resistance exercises at moderate intensity are recommended. There remains debate regarding the use of higher-intensity exercise, the appropriate outcome to measure efficacy, and the mechanisms driving the efficacy of exercise. IMPLICATIONS FOR NURSING PRACTICE: We provide background evidence and knowledge pertaining to the role and provision of exercise prehabilitation. Understanding screening, risk factors, and potential efficacy assists in knowing who to refer for prehabilitation and what the programs include. This enables more effective com munication with patients attending for cancer treatments.

A national survey of oncology physiotherapy services for cancer survivors in Australia.

BACKGROUND: Cancer is a leading cause of illness globally. Advancements in screening and treatment have led to improved survivorship. Physiotherapy is integral in improving survivorship for people with cancer, with strong evidence supporting the use of various physiotherapy services. However, the scope and extent of these services within clinical practice in Australia is unknown. AIM: Identify and describe physiotherapy service provision for cancer survivors in Australia and describe the scope of physiotherapy services provided to cancer survivors. METHODS: This cross-sectional study recruited physiotherapists and their respective managers involved in cancer service/s provision across Australia. Physiotherapy departments of tertiary hospitals and known oncology rehabilitation programs were contacted through a government directory and snowball sampling. The online survey included questions related to the extent and scope of service provision of physiotherapy for cancer survivors. Quantitative data were descriptively analyzed whereas open-ended responses were analyzed and presented narratively. RESULTS: Seventy-nine physiotherapy services were identified from 159 hospitals and/or health networks. Of the 55 (70%) responses received, 87% were from metropolitan areas, whereas 13% were regionally/rurally based services. Prehabilitation services mostly offered individual programs whereas rehabilitation programs had a mix of individual and group-based programs. The service content between prehabilitation and rehabilitation were similar, comprising primarily exercise-based interventions, followed by education and impairment-based therapies. CONCLUSION: Few designated physiotherapy services for cancer survivors exist in Australia. There is also disparity between service provision between metropolitan and regional/rural areas highlighting a need for clinicians, managers, and policy makers to invest more resources in establishing oncology physiotherapy services.

Factors associated with unplanned transfers among cancer patients at a freestanding acute rehabilitation facility.

BACKGROUND: Cancer patients undergoing inpatient rehabilitation often have high risk of complications leading to unplanned transfer to acute care. Prior studies have identified factors associated with these transfers but have been limited to examining factors that pertain to initial admission to rehabilitation and were not conducted in a freestanding inpatient rehabilitation facility. OBJECTIVE: The study aimed to include these prerehabilitation factors in addition to factors upon initial assessment in rehabilitation. It was hypothesized that specific factors from each of these periods would be associated with unplanned transfer to acute care. DESIGN: Retrospective cohort study. SETTING: Freestanding academic inpatient rehabilitation facility affiliated with an academic tertiary care facility with a comprehensive cancer center. PATIENTS: Retrospective review of 330 specific encounters unique to 250 patients from March 2017 to September 2018. MAIN OUTCOME MEASURES: The outcome measure was unplanned transfer to acute care. A binary logistic regression model was used to examine the relationship between factors from oncologic history, acute care course, and factors upon admission to rehabilitation to unplanned transfer to acute care. RESULTS: From 330 encounters, there were 111 unplanned transfers (34%). Unplanned transfer to acute care was independently associated with gastrointestinal malignancy (odds ratio [OR] 4.4, p = .01), 6-minute walk test less than 90 m (OR 4.6, p = .003), and prior unplanned transfer (OR 3.5, p = .007). CONCLUSIONS: The study suggests that oncologic and functional prerehabilitation markers are associated with an increased likelihood of unplanned transfer during inpatient cancer rehabilitation. These findings will provide a framework for creating predictive tools for unplanned transfers in cancer rehabilitation patients.