There is compelling evidence that exercise is safe for breast cancer patients during treatment and helps to manage many common side effects, as well as enhance quality of life, and overall health of cancer survivors [1
]. Furthermore, there are increasing calls for exercise to be adopted as part of standard of care in oncology in Canada [3
] and internationally [4
]. Cancer patients, however, report unique challenges to exercise adoption and maintenance, including concerns about safety, desire for guidance from exercise professionals trained to work with cancer patients, and physical limitations related to treatment side effects [5
Research has shown that women with newly diagnosed breast cancer may increase exercise when referred by their oncologist [9
]. Cancer patients in North America, however, currently have limited access to exercise programming outside of research protocols, especially during adjuvant treatment when the need is greatest with regards to symptom management and prevention of chemotherapy-associated deconditioning. There exists a gap between the scientific evidence and clinical practice regarding the use of exercise in the management of breast and other cancers. Potential reasons for the limited knowledge translation were well described by Santa Mina and colleagues [10
]. These include, among other factors, “an impression among clinicians that exercise may increase the risk of injury, fatigue and exacerbation of symptoms; overwhelmed and financially drained clinical programs; physical space restrictions; overall lack of clinicians with relevant exercise and clinical education and experience; and lack of discussion between patient and physician about exercise” [10
] (p. e137).
While there is emerging research regarding the experience of cancer patients involved in lifestyle interventions [11
], there is limited research examining patients’ perspectives regarding how lifestyle interventions are introduced and framed as part of comprehensive treatment within a cancer care setting. Specifically, what are patients’ perceptions and experiences when exercise and nutrition programming are prescribed by their oncologists? There has been even less exploration of the experience and perceptions of health professionals who have been engaged in referring patients to such lifestyle programs. One exception is the work of Smaradottir et al., who explored the perception of cancer patients and oncology healthcare professionals regarding the role of exercise in cancer care [15
]. Healthcare professionals were concerned about recommending exercise to frail and sedentary cancer patients and most preferred to defer to a specialist [15
]. Further understanding oncologists’ perceptions regarding their role in recommending exercise and nutrition interventions, as well as the challenges they face within busy ambulatory care settings, will shape future programming related to lifestyle behaviors in cancer care.
Our research team tested the feasibility of delivering a lifestyle intervention, the Nutrition and Exercise during Adjuvant Treatment (NExT) study, as part of standard of care for early stage breast cancer patients who were scheduled to receive adjuvant chemotherapy [16
]. Medical oncologists at a cancer center in Vancouver, Canada discussed the study with potentially eligible women. The oncologist completed a “prescription” form in duplicate (i.e., one copy to patient and one to the study staff) recommending the intervention. All referred women were screened. The intervention consisted of a supervised aerobic and resistance training intervention coinciding with adjuvant chemotherapy and radiation treatment (3 times/week for a mean of 25 weeks). This was followed by a transition to increased self-directed exercise and reduced frequency of supervised sessions (twice/week for 10 weeks, then once/week for another 10 weeks) such that the total prescription consisted of 150 min/week of moderate-intensity aerobic exercise and twice weekly resistance exercise. Participants were also invited to participate in a group-based nutrition counselling session, led by a registered dietitian with experience in working with breast cancer patients. Further details of the program, including outcomes, have been reported elsewhere [16
The purpose of the current study, a sub-study of the NExT parent study, was: (1) to explore breast cancer patients’ perspectives and experiences of being prescribed and subsequently engaging in exercise and nutrition programming at a large tertiary cancer treatment center; and (2) to explore medical oncologists’ perspectives and experiences in referring breast cancer patients to this intervention. The primary aim was to better understand the context within which the lifestyle intervention was recommended and experienced to shape future lifestyle programming and promote uptake in cancer care settings.
2. Materials and Methods
This sub-study used a qualitative descriptive approach [18
]. Eligible patients for the NExT parent study included English-speaking, adult (>18 years) women diagnosed with stage I–IIIA breast cancer, who were receiving adjuvant chemotherapy, and had medical approval and a referral by their medical oncologist to participate in the lifestyle intervention. Potential participants were excluded if they had a BMI of ≥ 40 kg/m2
, had mobility issues, or unstable cardiovascular disease or diabetes. To participate in the sub-study, women also had to have completed participation in the exercise component of the NExT parent study and were no longer receiving adjuvant chemotherapy. For further information about the NExT parent study, please see Kirkham et al.
Purposive sampling was used to invite patients and the medical oncologists who had participated in the parent study to join the sub-study. Diversity in age, socioeconomic status, geographical dwelling (rural/urban), and ethnicity was sought in the patient sample. All eight oncologists who had participated in the NExT parent study and had provided care to the participants were invited to take part in the sub-study.
Forty-three women who participated in the NExT study and eight oncologists were emailed letters of invitation. Interested women and oncologists were asked to contact the research team to arrange a time to complete a brief telephone or in-person interview. The NExT study and sub-study were approved by the University of British Columbia’s Clinical and Behavioural Research Ethics Boards (H12-02504 and H14-02805) and all procedures performed were in accordance with the 1964 Helsinki Declaration and its later amendments. All participants provided written informed consent. We confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.
2.1. Data Collection
One-on-one, semi-structured interviews were conducted with women and oncologists. The breast cancer patients’ interviews focused on their perceptions and experiences of having an oncologist prescribe a lifestyle intervention, their perception of the facilitators and challenges related to uptake and engagement in the intervention, and their recommendations regarding the role of oncologists and other health professionals in promoting lifestyle change. Oncologists’ interviews focused on how they perceived exercise and nutrition as part of conventional breast cancer treatment, their approach to introducing the NExT study to potential subjects, how they determined study eligibility, and their perceptions of the facilitators and challenges experienced by patients regarding study participation. Interviews were digitally recorded and transcribed verbatim, without identifying information. The interviews, which took 30–60 min to complete, were conducted by one team member (EW), who is experienced in qualitative research and a registered nurse. Brief questionnaires assessing patient’s demographics were completed, with treatment and diagnosis characteristics extracted from medical records.
2.2. Data Analysis
The interview data were analyzed beginning with line-by-line coding, with keywords, phrases, and concepts identified. Using a thematic analysis approach, this coding was then consolidated into a formal coding scheme following consultation with the research team. The coding scheme was piloted on two interviews (one patient and one oncologist) by two investigators (TT and LB) and any discrepancies or overlap in coding was discussed, with revisions made to the coding scheme. The interviews were then coded by hand using the revised coding scheme. Using this “codebook” approach to thematic analysis [19
], data which did not fit the coding scheme resulted in a new code beginning developed. Data were extracted based on the coding and reviewed for major themes and concepts. With regards to rigor, an audit trail was kept of all coding decisions as well as team meetings discussing the developing themes and concepts. A preliminary summary of the study findings was sent to the research team to ensure the trustworthiness of the data. No member checking with participants was undertaken due to time and costs constraints.
The study findings offer important insights into the facilitators and challenges of prescribing a lifestyle intervention for women with breast cancer undergoing adjuvant chemotherapy. While medical oncologists perceived a prescription as a significant motivating factor for breast cancer patients, the women described being motivated by the potential benefits of attending a breast cancer-specific lifestyle intervention, and their desire to improve their well-being following diagnosis. Which specific healthcare professional provided the prescription appeared to be less important to patients, other than it being a clinician with whom they had a trusting relationship. These findings were similar to Park et al., who found that an exercise recommendation solely from an oncologist was insufficient in motivating general exercise uptake in a breast and colorectal cancer population [21
]. Recommendations that were accompanied with an exercise motivation package (i.e., exercise DVDs, pedometer, diary, and education), however, were significantly more likely to result in increased exercise frequency and intensity [21
]. In contrast, Befort et al. found oncologist referrals to a lifestyle intervention for rural breast cancer survivors resulted in the highest enrolment rate [22
]. Taken together, these findings suggest that with the proper support, a cancer diagnosis may be a teachable moment for breast cancer patients to engage in risk-reducing health behaviors that hold the potential to improve morbidity and mortality [23
The benefits gained by patients went well beyond symptom management and improved physical fitness during adjuvant treatment. The program offered a trusted community where women’s psychosocial and physical needs could be addressed in a supportive manner. There has been increasing attention on the potential efficacy of non-traditional support groups, such as dragon boat teams [24
] and men’s sheds [25
], in addressing complex physical and psychosocial needs in a range of patient groups. The success of such groups in promoting healthy lifestyle behavior is, in part, a consequence of the sense of community, camaraderie, and purpose that develops among members.
The challenges reported by patients and oncologists focused mainly on contextualizing the lifestyle intervention to the unique needs of individuals (e.g., age, fitness goals, work, and family commitments). The lifestyle program used evidence-based guidelines to tailor the intervention to participants’ needs; however, social determinants of health or other factors that may have impacted individuals’ uptake of the intervention [26
] were not addressed. Buffart et al. [28
], in their summary of the current knowledge gaps in physical activity for cancer survivors, described the importance of moving beyond a one-size-fits all approach and tailoring exercise guidelines for individual characteristics, contexts, and capabilities for optimal uptake.
The findings have key practice implications. Oncologists and nurses can play a pivotal role in highlighting the importance and safety of lifestyle interventions during breast cancer treatment, and in motivating participation through tailored recommendations, and referrals to other health professionals, such as registered dietitians, physiotherapists, and registered kinesiologists, or to established community programming. Engaging primary care providers, such as family physicians and nurse practitioners, and ensuring nutrition and exercise are included in survivorship care plans will promote long-term support for cancer patients’ and survivors’ lifestyle modification maintenance. Continuing education, however, will be required to inform health professionals about the benefits of lifestyle interventions following a cancer diagnosis and to dispel myths regarding the ability of patients to engage in lifestyle modification while undergoing adjuvant cancer therapy. Recent Canadian and American surveys demonstrate that oncology nurses see the value of lifestyle interventions, and perceive patients to be receptive, but lack the necessary knowledge and counseling skills [29
Acknowledging the time and fiscal constraints in ambulatory cancer care settings, a streamlined process is required to support oncologists, nurses and other health professionals in prescribing and referring patients to lifestyle interventions. Utilizing peer mentors and volunteers in recruiting patients and supporting adherence may facilitate uptake of the lifestyle program with minimal impact on healthcare staff and resources. Accessibility may be enhanced through e-health technologies. Recent demonstrated efficacy of online mindfulness meditation programs [31
] and support groups [32
] reinforce e-technology use in promoting well-being among cancer patients. In addition, embedding the lifestyle intervention within regional oncology programs as well as local community centers with more flexible hours and locations may improve adherence, especially among younger patients with work and family responsibilities.
The study findings are not transferable to all lifestyle interventions situated in cancer care settings given the urban setting, small sample size, the use of an exercise and nutrition programming “prescription”, and the focus on breast cancer. In addition, the sample was primarily comprised of white or Asian, well-educated, and affluent women. The perspectives of those who did not participate were not captured, which may offer unique insights into the challenges of prescribing nutrition and exercise to newly diagnosed cancer patients.
Our findings support the need for exercise and nutrition to be embedded in standard cancer care and acknowledged early, and throughout, the breast cancer trajectory to address not only important physical and psychosocial needs experienced by patients undergoing adjuvant cancer treatment [33
], but also potentially improve all-cause mortality and reduce risk of recurrence [36
]. Including rehabilitative programs as a standard part of care may further reduce the economic burden experienced by women with breast cancer experiencing long-term adverse effects [37
]. Despite these important outcomes, implementing sustainable lifestyle programs in the clinical setting remains a challenge in cancer care. While high-quality exercise guidelines are available, other barriers must be addressed, such as space restrictions in cancer centers and out-of-pocket costs and travel time for patients [10
Although lifestyle prescriptions may be an efficient and familiar way for healthcare professionals to promote exercise and nutrition in cancer care settings, it is not as powerful a motivator as the content itself and the perceived physical, emotional, and social benefits. Lifestyle interventions have the potential to improve health outcomes, as well as provide women with a unique peer community for support and empowerment, and an opportunity to reframe their illness in a positive manner.
The study findings clearly indicate that cancer patients require support during but also after completion of treatment to adopt healthy lifestyle habits. Maintenance programs that transition patients into community settings and provide them with on-going information and follow-up about nutrition and exercise will reinforce the knowledge and skills gained during an initial lifestyle program that takes place during treatment in a clinical setting. Further, such maintenance programs have been found to support continued problem solving, empower patients to become more self-directed, and actively bolster self-accountability and motivation [39
]. Linking to existing community programs (i.e., cardiac rehabilitation) may provide a setting in which cancer patients and survivors can network and support one another [40