Moving effective interventions to new settings, with new people, can be a real hurdle for researchers attempting to get evidence-based programs into community settings. How do we maintain effectiveness while adapting the intervention for new contexts and new populations? Recently, the University of Alabama at Birmingham had a unique opportunity to apply “implementation science,” the process of examining methods or strategies that facilitate regular use of evidence-based research in practice, within exercise oncology. This opportunity moved forward the translational process of efficacy to effectiveness for our program1.
Regular physical activity improves health and well-being while reducing mortality risk in cancer survivors2,3, yet many cancer survivors do not meet the recommended guidelines for general health of at least 150 weekly minutes of moderate-intensity physical activity3-6. A variety of factors (including limited access to facilities, lack of awareness of resources and/or low motivation) likely contribute. Those living in rural locations are even less physically active, which may add, in part, to poorer health and quality of life in these populations7. As such, we were interested in delivering an exercise intervention to cancer survivors living in rural areas.
The Better Exercise Adherence after Treatment for Cancer (BEAT Cancer) intervention included supervised exercise, home-based (unsupervised) exercise and discussion group sessions for behavior-change support8. We demonstrated that this three-month physical-activity intervention for women with breast cancer significantly improved physical-activity adherence, with accompanying improvements in fitness, quality of life and a variety of patient-reported outcomes9-10.
We wondered if program delivery by non-research staff, such as community-based exercise professionals or discussion leaders in a non-research setting, would lead to similar program benefits. And could we expand the program to all women with a prior diagnosis of cancer, not just women who had experienced breast cancer?
We looked to principles from implementation science to guide our translation of an efficacious exercise oncology program in a rural setting.
The two main intervention adaptations made to the original BEAT Cancer intervention included new education materials (e.g., text, worksheets) for participants that were simplified and modified for application to any cancer type rather than only breast cancer, and new training materials to support the community interventionists. Additional adaptations included simplifying logistics by scheduling group sessions or supervised sessions more evenly over time rather than on a strictly tapered schedule, shortening group meeting duration, using exercise modes other than walking and shortening staff documentation formats. These adaptations improved the fit with the community organization’s staffing and resources while maintaining the core components of the original program.
How well did our transformation work?
Our results were similar to those of the original study, showing comparable within-group improvements related to physical activity, self-reported physical functioning, fatigue, mood, self-efficacy and overcoming barriers, thus providing proof-of-concept support for BEAT Cancer effectiveness. These results are particularly notable because the inclusion criteria for cancer survivors in this study were much less strict than for the original efficacy study, therefore facilitating a sample more representative of the “real world.”
In our Translational Journal of ACSM (TJACSM) article, we not only report on the adaptations used (an important concept in the field of implementation science),1 but also uniquely communicate the translation of a physical activity program for rural cancer survivors. We provide modification ideas and implementation challenges, such as logistical preparation, ensuring appropriate knowledge related to exercise training, resource considerations (cost, staff, etc.), program flexibility and longer participant follow-up. One main takeaway was the great value of and need for investment in building readiness and capacity for the delivery of exercise-oncology programs by non-research staff in community settings. Doing so will reap broad public health benefit.
To read more about our translational trial, and to gain insights about the exercise interventionists’ perspective on this translation of the exercise-oncology program, you can view the full article in TJACSM.
Laura Q. Rogers, M.D., MPH, FACP, FACSM, is a professor, Division of Preventive Medicine, Department of Medicine at the University of Alabama at Birmingham.
1. Phillips SM, Alfano CM, Perna FM, et al. Accelerating translation of physical activity and cancer survivorship research into practice: recommendations for a more integrated and collaborative approach. Cancer Epidemiol Biomarkers Prev. 2014;23(5):687–99. doi:10.1158/1055-9965.EPI-13-1355.
2. Campbell KL, Winters-Stone KM, Wiskemann J, et al. Exercise guidelines for cancer survivors: consensus statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019;51(11):2375–90. doi:10.1249/MSS.0000000000002116.
3. Patel AV, Friedenreich CM, Moore SC, et al. American College of Sports Medicine roundtable report on physical activity, sedentary behavior, and cancer prevention and control. Med Sci Sports Exerc. 2019;51(11):2391–402. doi:10.1249/MSS.0000000000002117.
4. LeMasters TJ, Madhavan SS, Sambamoorthi U, et al. Health behaviors among breast, prostate, and colorectal cancer survivors: a US population-based case-control study, with comparisons by cancer type and gender. J Cancer Surviv. 2014;8(3):336–48. doi:10.1007/s11764-014-0347-5.
5. Thraen-Borowski KM, Gennuso KP, Cadmus-Bertram L. Accelerometer-derived physical activity and sedentary time by cancer type in the United States. PLoS One. 2017;12(8):e0182554.
6. Littman AJ, Tang MT, Rossing MA. Longitudinal study of recreational physical activity in breast cancer survivors. J Cancer Surviv. 2010;4(2):119–27. doi:10.1007/s11764-009-0113-2.
7. Meit M, Knudson A, Gilbert T, et al. The 2014 Update of the Rural–Urban Chartbook. Bethesda (MD): Rural Health Reform Policy Research Center; 2014.
8. Rogers LQ, McAuley E, Anton PM, et al. Better exercise adherence after treatment for cancer (BEAT Cancer) study: rationale, design, and methods. Contemp Clin Trials. 2012;33(1):124–137. doi: 10.1016/j.cct.2011.09.004.
9. Rogers LQ, Courneya KS, Anton PM, et al. Effects of the BEAT cancer physical activity behavior change intervention on physical activity, aerobic fitness, and quality of life in breast cancer survivors: a multicenter randomized controlled trial. Breast Cancer Res Treat. 2015;149(1):109–19. doi:10.1007/s10549-014-3216-z.
10. Rogers LQ, Courneya KS, Anton PM, et al. Effects of a multicomponent physical activity behavior change intervention on fatigue, anxiety, and depressive symptomatology in breast cancer survivors: randomized trial. Psycho-Oncology. 2017;26(11):1901-1906. doi:10.1002/pon.4254.