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

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

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

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

OptiBra study, a randomized controlled trial on optimal postoperative bra support after breast cancer surgery.

AIM: This randomized controlled trial aimed to compare two different postoperative bras after breast cancer surgery and evaluate their impact on primary outcome pain. METHOD: The study included 201 patients scheduled for primary surgery (breast conserving surgery with sentinel node biopsy or axillary clearance, mastectomy, or mastectomy with primary implant reconstruction with sentinel node biopsy or axillary clearance). Participants were randomized to either a soft bra or stable bra with compression. The patients were recommended to use the bra 24 h/day for 3 weeks, record daily pain (NRS), analgesic use and hours of bra use. RESULTS: Follow up was completed by 184 patients. No significant differences between the arms were found considering pain score over time, neither day 1-14, nor after 3 weeks. Sixty-eight percent of all patients, regardless of randomization, reported pain during the first 14 days. After 3 weeks 46% still reported pain in the operated breast. Among these, patients randomized to the stable bra with compression reported significantly lower pain score than those randomized to the soft bra. Patients who used the stable bra with compression reported significantly higher levels of comfort, sense of security during activity, less difficulty moving the arm, as well as support and stability for the operated breast compared to those using the soft bra. CONCLUSION: Using a stable bra with compression is the optimal evidence-based choice after breast cancer surgery to reduce remaining pain 3 weeks after surgery, increasing mobility, comfort, and sense of security. TRIAL REGISTRATION NUMBER: NCT04059835 at www. CLINICALTRIALS: gov.

A pedagogical model to enhance nurses' ability to support patient learning: an educational design research study.

Objectives: To design, apply, evaluate, and analyse a pedagogical model to enhance nurses' ability to create pedagogical encounters to support patients' learning. Methods: The study relies on an educational design research approach. A pedagogical model based on learning theories was designed, applied, evaluated, and analysed in a specialist nursing programme in cancer care. All students (n=28) who attended the programme accepted to participate in the evaluation of the model. Their perception of the learning activities was evaluated in a questionnaire, and 16 (57%) students responded. The students' learning was assessed in written assignments, including all students. Descriptive statistics, content analysis and theoretical reasoning, were used to analyse data and interpret the usefulness and shortcomings of the model. Results: The most appreciated learning activities were to study learning theories, observe pedagogical encounters, act as a critical friend, and document one's own pedagogical encounters. The written assignments about observing and performing their own pedagogical encounters with patients showed students' increased awareness of how to support patients' learning. The clinical supervisors' lack of pedagogical knowledge inhibited the feedback on students' performances. Conclusions: The theoretical analysis of the evaluation identified strengths and needs for further development. The strengths tend to be the ongoing learning process created by learning activities supporting students to continuously study, experience, and apply their knowledge. Nurse supervisors and other stakeholders at the clinics are suggested to be involved in improving the design and require pedagogical competence. Further research should include observational and interview studies related to students' performance in pedagogical encounters.

Effect of self-managed lifestyle treatment on glycemic control in patients with type 2 diabetes.

The lack of effective, scalable solutions for lifestyle treatment is a global clinical problem, causing severe morbidity and mortality. We developed a method for lifestyle treatment that promotes self-reflection and iterative behavioral change, provided as a digital tool, and evaluated its effect in 370 patients with type 2 diabetes (ClinicalTrials.gov identifier: NCT04691973). Users of the tool had reduced blood glucose, both compared with randomized and matched controls (involving 158 and 204 users, respectively), as well as improved systolic blood pressure, body weight and insulin resistance. The improvement was sustained during the entire follow-up (average 730 days). A pathophysiological subgroup of obese insulin-resistant individuals had a pronounced glycemic response, enabling identification of those who would benefit in particular from lifestyle treatment. Natural language processing showed that the metabolic improvement was coupled with the self-reflective element of the tool. The treatment is cost-saving because of improved risk factor control for cardiovascular complications. The findings open an avenue for self-managed lifestyle treatment with long-term metabolic efficacy that is cost-saving and can reach large numbers of people.

Highly favorable physiological responses to concurrent resistance and high-intensity interval training during chemotherapy: the OptiTrain breast cancer trial.

BACKGROUND: Advanced therapeutic strategies are often accompanied by significant adverse effects, which warrant equally progressive countermeasures. Physical exercise has proven an effective intervention to improve physical function and reduce fatigue in patients undergoing chemotherapy. Effects of high-intensity interval training (HIIT) in this population are not well established although HIIT has proven effective in other clinical populations. The aim of the OptiTrain trial was to examine the effects of concurrent resistance and high-intensity interval training (RT-HIIT) or concurrent moderate-intensity aerobic and high-intensity interval training (AT-HIIT), to usual care (UC) on pain sensitivity and physiological outcomes in patients with breast cancer during chemotherapy. METHODS: Two hundred and forty women were randomized to 16 weeks of RT-HIIT, AT-HIIT, or UC. OUTCOMES: cardiorespiratory fitness, muscle strength, body mass, hemoglobin levels, and pressure-pain threshold. RESULTS: Pre- to post-intervention, RT-HIIT (ES = 0.41) and AT-HIIT (ES = 0.42) prevented the reduced cardiorespiratory fitness found with UC. Handgrip strength (surgery side: RT-HIIT vs. UC: ES = 0.41, RT-HIIT vs. AT-HIIT: ES = 0.28; non-surgery side: RT-HIIT vs. UC: ES = 0.35, RT-HIIT vs. AT-HIIT: ES = 0.22) and lower-limb muscle strength (RT-HIIT vs. UC: ES = 0.66, RT-HIIT vs. AT-HIIT: ES = 0.23) were significantly improved in the RT-HIIT. Increases in body mass were smaller in RT-HIIT (ES = - 0.16) and AT-HIIT (ES = - 0.16) versus UC. RT-HIIT reported higher pressure-pain thresholds than UC (trapezius: ES = 0.46, gluteus: ES = 0.53) and AT-HIIT (trapezius: ES = 0.30). CONCLUSION: Sixteen weeks of RT-HIIT significantly improved muscle strength and reduced pain sensitivity. Both exercise programs were well tolerated and were equally efficient in preventing increases in body mass and in preventing declines in cardiorespiratory fitness. These results highlight the importance of implementing a combination of resistance and high-intensity interval training during chemotherapy for women with breast cancer.

Adding high-intensity interval training to conventional training modalities: optimizing health-related outcomes during chemotherapy for breast cancer: the OptiTrain randomized controlled trial.

PURPOSE: Exercise training is an effective and safe way to counteract cancer-related fatigue (CRF) and to improve health-related quality of life (HRQoL). High-intensity interval training has proven beneficial for the health of clinical populations. The aim of this randomized controlled trial was to compare the effects of resistance and high-intensity interval training (RT-HIIT), and moderate-intensity aerobic and high-intensity interval training (AT-HIIT) to usual care (UC) in women with breast cancer undergoing chemotherapy. The primary endpoint was CRF and the secondary endpoints were HRQoL and cancer treatment-related symptoms. METHODS: Two hundred and forty women planned to undergo chemotherapy were randomized to supervised RT-HIIT, AT-HIIT, or UC. Measurements were performed at baseline and at 16 weeks. Questionnaires included Piper Fatigue Scale, EORTC-QLQ-C30, and Memorial Symptom Assessment Scale. RESULTS: The RT-HIIT group was superior to UC for CRF: total CRF (p = 0.02), behavior/daily life (p = 0.01), and sensory/physical (p = 0.03) CRF. Role functioning significantly improved while cognitive functioning was unchanged for RT-HIIT compared to declines shown in the UC group (p = 0.04). AT-HIIT significantly improved emotional functioning versus UC (p = 0.01) and was superior to UC for pain symptoms (p = 0.03). RT-HIIT reported a reduced symptom burden, while AT-HIIT remained stable compared to deteriorations shown by UC (p < 0.01). Only RT-HIIT was superior to UC for total symptoms (p < 0.01). CONCLUSIONS: 16 weeks of resistance and HIIT was effective in preventing increases in CRF and in reducing symptom burden for patients during chemotherapy for breast cancer. These findings add to a growing body of evidence supporting the inclusion of structured exercise prescriptions, including HIIT, as a vital component of cancer rehabilitation. TRIAL REGISTRATION: Clinicaltrials.gov Registration Number: NCT02522260.

Experiencing health - Physical activity during adjuvant chemotherapy treatment for women with breast cancer.

PURPOSE: The aim of this study was to explore how women with breast cancer experience physical activity (PA) during adjuvant chemotherapy treatment. METHODS: This study included sixteen women diagnosed with breast cancer who had participated in a supervised 16-week PA intervention during adjuvant chemotherapy treatment. The qualitative approach included semi-structured individual and focus group interviews. Data were analyzed inductively with content analysis. RESULT: The content analysis resulted in a description of experiencing health during chemotherapy treatment covered by five categories: Solidarity with others and being good to oneself; Experiencing functional improvement and social support; Empowerment and motivation to focus on health; Barriers to adherence to PA during illness and treatment; and Enabling health and independence. A core category was identified; PA a tool for maintenance and recovery of physical, mental and social health. The women reported that PA had a positive impact on both physical function and mental wellbeing. Participating in the PA intervention also increased their feeling of social support, which was reported to be important to motivate adherence to PA when the side effects became more severe. Symptom burden, time and lack of motivation were reported as barriers to continue PA during treatment. CONCLUSION: The women in this study reported that PA had a positive impact on their perceived health and that it was possible to exercise despite increasing symptom burden from treatment. PA was perceived as a tool that supported health processes and gave the women a feeling of getting respite from the illness.

A randomized pilot study with daily walking during adjuvant chemotherapy for patients with breast and colorectal cancer.

BACKGROUND: Physical activity during chemotherapy has been shown in several studies to reduce fatigue, improve symptoms and impact positively on health-related quality of life (HRQoL). Challenges associated with intervention studies on physical activity during cancer treatment relate to consistent adherence. The primary objective was to study feasibility and adherence of physical activity intervention among patients with cancer during adjuvant chemotherapy treatment. The secondary objective was to investigate the effects of physical activity on health aspects, including HRQoL, symptoms and surrogate markers for cardiovascular disease. MATERIAL AND METHODS: This randomized controlled trial included patients with breast cancer (BRCA) and colorectal cancer (CRC) during adjuvant chemotherapy. The intervention continued for 10 weeks and included daily walks of 10 000 steps and a weekly supervised group walk. Adherence was assessed by a pedometer and the number of participants who reported step counts every week and percentage of participants who achieved the target steps every week. RESULTS: Adherence average reached 91% during the intervention period; in total 74% completed the exercise intervention. The majority of the participants achieved an average of 83% of the target of 10 000 steps per day for 10 weeks. There was a significant increase in daily physical activity (p = 0.016) in the intervention group. Significant differences were also found for some breast cancer-specific symptoms [swelling, mobility and pain (p = 0.045)]. The study showed a relatively small weight gain an average of 0.9 kg in the intervention group and 1.3 kg in the control group. CONCLUSION: Physical activity in the form of walking is feasible during adjuvant chemotherapy treatment despite increasing symptoms. The physical activity increased in the intervention group during the study time and had a positive impact on breast symptoms and the weight gain was lower in comparison to previous studies.