Introduction
Methods
Research objective
Study eligibility
Information sources and search
Article screening and selection
Data extraction and analysis
Outcomes | Definition | Measurement metrics |
Reach/Penetration | The absolute representativeness of individuals, including healthcare providers and patients, and organizations who are willing to utilize exercise services integrated as part of cancer care | • Total number of referrals for exercise-based rehabilitation relative to the total eligible patient population |
Service uptake/adoption | Service utilization by an organization as evidenced by reports on the total number of staff referring patients for exercise-based rehabilitation | • Number of patient referrers |
Acceptability | The extent to which exercise services is deemed suitable, satisfactory, and attractive to the patients or the healthcare providers | • Number of accepted referrals • Service compliance (including attrition) • Adverse events |
Patient satisfaction | The extent to which exercise services is deemed satisfactory by the patients | • Documented reports on patient satisfaction |
Implementation | The extent to which exercise-based rehabilitation can be delivered to the intended population successfully | • Workforce • Equipment • Service promotion • Referral mechanism/pathway • Program structure • Session duration • Funding |
Cost | The cost implications of service implementation | • Salaries • Purchase cost • Delivery cost |
Fidelity | The degree of service providers’ compliance with existing pre-implementation plan and recommendation guidelines | • Documented efforts including strategies to ensure fidelity including consistency of service delivery |
Sustainability | The extent to which exercise services becomes institutionalized as a standard in routine cancer care | • [infra]structural adjustments • Increased workforce • Increased funding |
Results
Study description
Author Country | Study | Population | Healthcare setting | Exercise service | Service description | Implementation outcomes |
---|---|---|---|---|---|---|
Dennett 2021 [27]; Dennett 2021 [28] Australia | Design: Prospective pre-post designQualitative exploration Evaluation: 6 months | Adult cancer survivors (n = 64) currently receiving or preparing for cancer treatment (curative or palliative) admitted as an inpatient or outpatient Age: 63 ± 11yrs Gender: Male: n = 41; 56%; Female: n = 32, 44% | Cancer unit — inpatient oncology ward + outpatient day oncology center offering chemotherapy — embedded in a publicly funded tertiary hospital | Exercise-based rehabilitation within a hospital-based cancer treatment center | Individually tailored, physiotherapist-led group-based circuit exercise class Frequency: 1-2x/wk Duration: 8 weeks | All |
Kennedy 2020 [29]; Newton 2020 [30] Australia | Design: Retrospective evaluation Evaluation: 50 months | Individuals (n = 73) receiving radiation therapy and/or chemotherapy Median age: 58.5; IQR: 48-67) Gender: Female: n = 43, 67.2%; male: n = 21, 32.8% Cancer type: Breast: n = 39, 60.9%; Prostate: n = 13, 20.3%; Colorectal: n = 3, 4.7%; Lung: n = 3, 4.7%; Other: n = 6, 9.4% Secondary cancer report: n = 3, 4.8% Treatment type: Radiation: n = 55, 85.9%; Chemo: n = 4, 6.3%); Radio + chemo: n = 5, 7.8% | Private oncology care clinic (GenesisCare) providing primarily outpatient-based radiation therapy and medical oncology treatments | Exercise service Clinic (Co-LEC) established in 2013 by researchers from Edit Cowan University, in partnership with GenesisCare | Patient tailored (progressive)/group-based resistance (2-3 sets; 6-12 reps) + aerobic exercise (20mins; 60%-80% estimated HRmax) delivered by an AEP Frequency: 60mins/session; 2-3x/wk Duration: Throughout treatment course (Average: 13wks) | All |
Dalzell 2017 [31] Canada | Design: Prospective Evaluation: 60 months | 234 new and follow-up cancer patients e.g., sample demographics for sample 2 months evaluation (multiple cancer types;) Mean Age: 52 ± 15.5yrs Female: 65% Patients on active treatment: 52% Patients with advanced disease or metastatic cancer: 35.5% Bone metastasis: 16% Bone metastasis: 16% | Integrated oncology and palliative care center within a publicly funded general hospital | Multimodal rehabilitation care model with hospital-based exercise oncology referral component (ActivOnco) embedded in a cancer center | Individualized plus group-based multicomponent exercise with patient education, exercise counseling, and self-management | All but sustainability and cost |
Dennett 2017 [32] Australia | Design: Ex post facto design using mixed methods approachEvaluation: 2 wks | Patients with different cancer diagnoses, disease stages, and treatment status | Public and private hospitals/cancer centers across 6 states/territories | 31 eligible programs identified from 56 public settings and 9 private settings | Individualized exercise program (Block = 14 programs; rolling = 17 programs) comprising mainly a combination of aerobic, resistance, and flexibility exercise 6-10 patients/session Frequency/duration: Outpatient: 2x/wk for 8wks; inpatient: 2x/day for the duration of inpatient stay (~ 2 wks) | All but sustainability and cost |
Summary of implementation
Dalzell 2017 [31] | Dennett 2017 [32] | |||
---|---|---|---|---|
Implementation | Workforce Employed clinical staff: 1 Senior physiotherapist (20hr/wk) 1 Mid-level physiotherapist (19.5hr/wk) Support staff: 1 senior research physiotherapist Service operation Resources: physiotherapy gym with existing equipment Average wait time to the first appointment: 20 days (range 0–99) Average time taken for first appointment: 51 min (SD 7) Service access: 4d/wk (Mon-Thur) Attendance option: 1x or 2x/wk (Ihr/session) Clinician to patient ration (per group class): 1:4 Service promotion: Within and outside health facility (e.g., flyer, poster, newsletter) with the aid of the organization’s communications officer Referral mechanism: Direct verbal referral (i.e., in-person, telephone); use of centralized email address (i.e., by including patient name/contact details); self-referralClinicians were encouraged to have a brief conversation on exercise with patients prior to referrals. Transition plan: Patients were referred to community-based rehab, existing sub-acute multidisciplinary Cancer rehab, home-based rehab, and occupational therapy | Workforce: 4 AEPs including consultants (AEPs were separate to the patient core care team) Service operation: Independent of the cancer center: patient triage and integrated medical record were lacking Resources: Provided by ECU Service access: 3days/wk; 2hrs/session with lack of co-ordination between gym and treatment times Service promotion: Not reported Referral mechanismPathway: direct verbal referrals from clinicians; self-referralReferrals were made only when oncologists remembered and had the time | Workforce: 5 physiotherapists (I clinical director and 4 staff physiotherapists) + 3 kinesiologists with training and experience in oncology Service operation: Independent of the cancer center Resources: Provided by Hope and Care Service promotion: Presentations on the values of exercise interventions to various departments Referral mechanism: well-defined patient triage and referral pathwaysSources include oncologists, allied health workers, self-referral, other sources including wellness centers Transition plan: Home-based exercise program, wellness center | Workforce: Physiotherapy: 21/31 programs; Exercise Physiology: 20/31 programs Service promotion: Exercise fliers, letters to GPs, community awareness programs Service structure: outpatient programs: 2x/wk for 8 wks; inpatient programs: 2x/day for the duration of inpatient stay (approximately 2 weeks) Early morning sessions were less practical and received the lowest patient attendance Developing flexible and rolling program is critical to enhancing practicality Referral mechanism Patient feedback to their primary doctors was a key driver of more referrals from doctors Transition plan: Home-based exercise program, community groups |
Cost | Funding: External service improvement grant Cost to patient: no cost Health service Staffing, e.g., payment of salaries: AUD $160,916 Consumables: Mobile phone costs (AUD $180; $30 per month)Printing of assessment forms and home exercise programs (5 pages per patient x 73 patients @ 0.66 c /page) (AUD $2) Total Cost: AUD $161,098 Cost to health service per patient: AUD $1,104 | Funding: ECU research grant Cost to patient: no cost Operational cost was covered through a research grant | Funding: Private donations | Funding sources: public = 14; private = 17 |
Reach/Penetration | ~10% of patients treated in the cancer center (i.e., 155 referrals including self-referrals) | 12% (i.e., 237 out of 1963 patients that received cancer treatment over a 50-month period) Average annual reach = 10-14% | 1635 patients over a 5-year evaluation period, with an average of 5.8 follow-up visits | 31 eligible programs identified from 46 public hospitals/cancer centers and 39 private hospitals/centers across 6 out of 8 states/territories |
Service uptake | 46 staff made 148 referrals over the 6 months evaluation period: medical: n = 32, 22%; nurses: n = 53, 36%; allied health: n = 63, 43% Facilitators of service utilization: Service visibility, convenience, building rapport, accessibility, timing, and staff experience | Number of oncologists with at least 1 patient attending Co-LEC = 11/11 Sources of referrals: oncologists = 21%; nurses = 20% | Referrals were largely from oncologists (35%) and nurses (36%) (e.g., over a 2-month referral period) | Referral sources: oncologists (28/31 programs); allied health clinicians (21/31 programs) Poor knowledge among doctors on the role of exercise in cancer management was a major limiting factor |
Acceptability | 44% (52* out of eligible 119 patients) Refused referrals: n = 67, 43% [Reasons: not interested (n = 17), unsure (n = 16), unwell/treatment related (n = 3), work (n = 2), location/parking (n = 2), home-based exercise (21) other (n = 6)] No. of refusals after 1st session: n = 2 (reason: readmission = 1) Compliance: 38 patients elected for 2x/wk with 56% completing 7/16 sessions; 14 patients elected for 1x/wk with 40% completing 3/8 sessions Missed sessions were due to: Refusal (25%) Unwell due to treatment (23%) Drop out: n = 20; 38% (Reasons: COVID-19 restrictions; hospital readmission, disease progression) | 27% (i.e., 64 out of 237 referrals over a 50 month) Common reason for non-service utilization was lack of awareness of its availability | 71% compliance (over 3 years) in a sample of 41 patients with multiple myeloma (81% had bone lesion) on active treatment Dropouts: Increased with the incidence of skeletal-related events, including pathologic fracture, spinal cord compression, and radiation for stabilization of bone lesions | Overall, annual enrolment per program: 10-70 patients; 2000 survivors per year across Australia |
Satisfaction | n = 57#, 100%) Access (timing, facility, location): n = 46, 81% Willingness to recommend others to participate during treatment: n = 57, 100% Feeling of improved overall health/wellbeing: n = 56, 98% Sources of dissatisfaction Difficulties with access: n = 6, 8% Difficulties were largely due to lack of parking space | Social value: n = 11 out of 61 patients Improved treatment experience: 12 out of 61 patients Positivity: 24/61 patients Staff experience/professionalism: 17/61 patients Sources of dissatisfaction Lack of coordination between treatment and gym times: 33/51 patients Parking issues: 5/51 patients Lack of transition plan at the end of the program: 4/51 patients | — | Patient cantered: programs addressed individual patient needs and goals Programs increased opportunities for social support Sources of dissatisfaction Program timing (attendance were lowest for early morning sessions) Parking issues Travel distances particularly for metropolitan centers |
Fidelity | Exercise service was implemented by clinicians with 5.5 years oncology-specific experience and prior cancer-specific training in acute and community cancer settings. A steering committee comprising a consumer, clinical directors, physiotherapy manager and a community partner ensured service implementation Program staff and other hospital physiotherapists received three 1hr education sessions on cancer and rehabilitation Medical, nursing, and allied health staff received 3 presentations to provide updates throughout program implementation | Service implementation was spearheaded by 3 AEPs with experience in exercise oncology | Continuous staff mentoring and education | — |
Sustainability | Philanthropic funds were sought to pay staff salaries to sustain the program beyond the pilot period | Funding: Direct clinical operational cost was covered by ECU and GenesisCare to support service continuation at the end of the feasibility phase Structural adjustments (mainly due to inadequate funds): Operational hours reduced to 2hrs/wk (1hr/2days/wk) Eligibility was rescinded for patients receiving chemotherapy alone Service duration was reduced to 3 months for all patients regardless of treatment duration Challenges Communication gap between ECU and GenesisCare Financial model was lacking— Co-LEC was not generating revenue | — | — |