It is well documented that physical activity (PA) benefits patients with cancer, both during and after treatment. Exercise helps patients combat both physical and psychological impacts of cancer treatment, giving them a sense of well-being, control, stress reduction, and empowerment. However, exactly what constitutes an appropriate PA recommendation within a multimodal cancer treatment plan is unclear.
To uncover barriers to PA recommendations in patients with cancer, researchers from Gundersen Health System in Wisconsin facilitated a focus group study. The researchers, led by Agnes Smaradottir, MD, Medical Oncologist, found that 95% of patients surveyed felt they benefited from exercise during treatment, but only three of the 20 patients recalled being instructed to exercise. Moreover, while all practitioners noted that exercise benefits patients, though not all patients, only one of the nine surveyed documented discussion of exercise in patient charts.
The study, “Are We on the Same Page? Patient and Provider Perceptions about Exercise in Cancer Care: A Focus Group Study,” published in the May 2017 issue of JNCCN – Journal of the National Comprehensive Cancer Network is available free of charge on JNCCN.org until July 30, 2017.
“Our results indicate that exercise is perceived as important to patients with cancer, both from a patient and physician perspective; however, physicians are reluctant to consistently include PA recommendations in their patient discussions. Our findings highlight the value of examining both patient and provider attitudes and behavioral intentions,” said Dr. Smaradottir. “While we uncovered barriers to exercise recommendations, questions remain on how to bridge the gap between patient and provider preferences.”
Where they exercise is important to patients. More than 80% of those surveyed noted that they would prefer a home-based exercise regimen that could be performed in alignment with their personal schedules and symptoms. Patients also noted a preference that exercise recommendations come from their oncologists, as they have an established relationship and feel that their oncologists best understand the complexities of their personalized treatment plans.
Although patients prefer PA at home, Dr. Smaradottir found that practitioners wish to refer patients to specialist care for exercise recommendations. The practitioners surveyed noted not only mounting clinic schedules, but also a lack of education about appropriate PA recommendations for patients. Furthermore, they expressed concern about asking patients to be more physically active during chemotherapy and radiation, and also expressed trepidation about prescribing PA to frail patients with limited mobility.
“We were surprised by the gap in expectations regarding exercise recommendation between patients and providers. Many providers, ourselves included, thought patients would prefer to be referred to an exercise center, but they clearly preferred to have a home based program recommended by their oncologist,” Dr. Smaradottir said.
Exercise was felt to be an equally important part of treatment and well-being for patients with early stage cancer treated with curative intent as well as patients receiving palliative therapy.
For the focus groups, the investigators interviewed 20 patients aged 45 and older – 10 with stage I-III non-metastatic cancer after adjuvant therapy and 10 with stage IV metastatic disease undergoing palliative treatment, both across multiple tumor types. Additionally, the researchers interviewed nine practitioners. The authors note that while the sample size is limited, because the subjects of the study all hailed from the same institution, the study provides an understanding of how the group as a whole has the potential to influence the practice of PA recommendations.
Smaradottir et al note that physician education is paramount and suggest that successful implementation of an education protocol should begin with a multidisciplinary collaboration between treating providers and physical therapy specialists, exercise physiologists, and other subspecialties. They add that the emphasis of such a program should be on a patient-centered approach, making the recommendations specific for each patient.
“Indeed, physicians, fellows, and residents who collaborate with a PA specialist through a shared-care clinic visit will gain valuable education about how to discuss exercise recommendations with their patients,” said Dr. Smaradottir.
Currently, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Survivorship recommend exercise for cancer survivors.
“Physical activity is emerging as an important adjunct therapy in the treatment of multiple cancers, and there is consensus that physical activity is helpful to patients with cancer and survivors in terms of augmenting symptom burden and maintaining overall health. This study highlights the discord between what we think is important and what we do in actual practice as providers. It also highlights patients’ desire to remain physically active and to receive guidance from their oncologists regarding what they can and should be doing. Based on the results of this and other studies, further work on both defining what the optimal physical activity recommendation for patients should be and determining how best to train our oncologic workforce to implement recommendations is needed,” said Crystal Denlinger, MD, Chief of Gastrointestinal Medical Oncology and Associate Professor, Department of Hematology/Oncology at Fox Chase Cancer Center, and Chair of the NCCN Guidelines® Panel for Survivorship.
Free access to this article is available until July 30, 2017, on JNCCN.org.
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About the National Comprehensive Cancer Network
The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 27 leading cancer centers devoted to patient care, research, and education, is dedicated to improving the quality, effectiveness, and efficiency of cancer care so that patients can live better lives. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.
The NCCN Member Institutions are: Fred & Pamela Buffett Cancer Center, Omaha, NE; Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; City of Hope Comprehensive Cancer Center, Los Angeles, CA; Dana-Farber/Brigham and Women’s Cancer Center | Massachusetts General Hospital Cancer Center, Boston, MA; Duke Cancer Institute, Durham, NC; Fox Chase Cancer Center, Philadelphia, PA; Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT; Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, WA; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL; Mayo Clinic Cancer Center, Phoenix/Scottsdale, AZ, Jacksonville, FL, and Rochester, MN; Memorial Sloan Kettering Cancer Center, New York, NY; Moffitt Cancer Center, Tampa, FL; The Ohio State University Comprehensive Cancer Center – James Cancer Hospital and Solove Research Institute, Columbus, OH; Roswell Park Cancer Institute, Buffalo, NY; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, MO; St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center, Memphis, TN; Stanford Cancer Institute, Stanford, CA; University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL; UC San Diego Moores Cancer Center, La Jolla, CA; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA; University of Colorado Cancer Center, Aurora, CO; University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; The University of Texas MD Anderson Cancer Center, Houston, TX; University of Wisconsin Carbone Cancer Center, Madison, WI; Vanderbilt-Ingram Cancer Center, Nashville, TN; and Yale Cancer Center/Smilow Cancer Hospital, New Haven, CT.