Evaluation of two strategies to implement physical cancer rehabilitation guidelines for survivors of abdominopelvic cavity tumors:a controlled before-and-after study

PURPOSE: This study evaluates the effectiveness and feasibility of two strategies to implement physical cancer rehabilitation (PCR) guidelines for patients who have survived abdominopelvic cavity malignancies. METHODS: We tested and compared two tailored strategies to implement PCR guidelines for survivors of gastrointestinal, female organ and urogenital organ malignancies, in a clustered controlled before-and-after study. A patient-directed (PD) strategy was tested in five cancer centers, aiming to empower survivors. A multifaceted (MF) strategy was tested in four cancer centers, aiming additionally to influence healthcare professionals and the healthcare organization. Data were collected from existing registration systems, patient questionnaires and professional questionnaires. We measured both implementation- and client outcomes. For insight into the effectiveness we measured indicators related to PCR guidelines: (1) screening with the Distress Thermometer (DT) (=primary outcome measure), (2) information provision concerning physical activity (PA) and physical cancer rehabilitation programs (PCRPs), (3) advice to take part in PA and PCRPs, (4) referral to PCRPs, (5) participation in PCRPs, (6) PA uptake (PAU); and patient reported outcomes (PROs) such as (7) quality of life, (8) fatigue, and (9) empowerment. Furthermore, survivor and center determinants were assessed as possible confounders. Multilevel analyses were performed to compare the scores of the indicators of the PD and MF strategies, as well as the differences between the characteristics of these groups. The use of and experiences with both strategies were measured using questionnaires and Google Analytics to assess feasibility. RESULTS: In total, 1326 survivors participated in the study, 673 in the before- and 653 in the after-measurement. Regarding our primary outcome measure, we found a significant improvement of screening with the DT between the before- and after-measurement for both strategies, respectively from 34.2 to 43.1% (delta=8.9%; odds ratio (OR)=1.6706; p=0.0072) for the PD strategy and from 41.5 to 56.1% (delta=14.6%; OR=1.7098; p=0.0028) for the MF strategy. For both the primary and secondary outcomes, no statistically significant effect of the MF strategy compared to the PD strategy was observed. We found good use of and positive experiences with both strategies. CONCLUSION: Implementation strategies containing tools enhancing patient empowerment seem to be effective in increasing the systematic screening with the DT for survivors of abdominopelvic cavity malignancies. Further research is needed to assess the additional effectiveness of strategies that stimulate compliance among healthcare professionals and healthcare organizations. IMPLICATIONS FOR CANCER SURVIVORS: Using implementation strategies containing tools enhancing patient empowerment seem to be effective in increasing the systematic screening with the DT and might improve the quality of care of patients who have survived abdominopelvic cavity malignancies. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11764-021-01045-3

Study protocol: an evaluation of the effectiveness, experiences and costs of a patient-directed strategy compared with a multi-faceted strategy to implement physical cancer rehabilitation programmes for cancer survivors in a European healthcare system; a controlled before and after study

Background The need for physical cancer rehabilitation programmes (PCRPs), addressing adverse effects from cancer, is growing. Implementing these programmes into daily practice is still a challenge. Since barriers for successful implementation often arise at different levels in healthcare, multi-faceted strategies focusing on multiple levels are likely more effective than single-faceted strategies. Nevertheless, most studies implementing PCRPs used strategies directed at patients only. The aim of this study is to develop and identify the most effective strategy to implement PCRPs into daily care. We want to assess the added value of a multi-faceted strategy compared with a single-faceted patient-directed strategy. Methods/design We will conduct a clustered controlled before and after study (CBA) in the Netherlands that compares two strategies to implement PCRPs. The patient-directed (PD) strategy (five hospitals) will focus on change at the patient level. The multi-faceted (MF) strategy (five hospitals) will focus on change at the patient, professional and organizational levels. Eligibility criteria are as follows: (A) patients: adults; preferably (history of) cancer in the gastro-intestinal, reproductive and/or urological system; successful primary treatment; and without recurrence/metastases. (B) Healthcare professionals: involved in cancer care. A stepwise approach will be followed: Step 1: Analysis of the current implementation of PCRPs and the examination of barriers and facilitators for implementation, via a qualitative study with patients (four focus groups n = 10–12) and their healthcare workers (four focus groups n = 10–12 and individual interviews n = 30–40) and collecting data on adherence to quality indicators (n = 500 patients, 50 per hospital). Step 2: Selection and development of interventions to create a PD and MF strategy during expert roundtable discussions, using the knowledge gained in step 1 and a literature search of the effect of strategies for implementing PCRPs. Step 3: Test and compare both strategies with a clustered CBA (effectiveness, process evaluation and costs), by data extraction from existing registration systems, questionnaires and interviews. For the effectiveness and cost-effectiveness, n = 500 patients, 50 per hospital. For the process evaluation, n = 50 patients, 5 per hospital, and n = 40 healthcare professionals, 4 per hospital. Main outcome measures: % screened patients, % referrals to PCRPs, incremental costs and incremental cost-effectiveness ratios (ICERs)

Proton-based RT enables target dose escalation in oesophageal cancer with limited impact on OAR dose

Purpose or ObjectiveOesophageal cancer (EC) patients with a clinical complete response after neo-adjuvant chemoradiotherapy (nCRT) might be candidates for organ preservation. Thomas et al. (2019) demonstrated that higher radiation dose improves the rate of major pathologic response. The ARTDECO trial (2021) showed a trend towards better local control in the high dose arm in definitive setting. However, dose escalation using photon-based RT failed to result in improved overall survival. This might be related to higher normal tissue dose and consequently higher toxicity risks. The aim of this in silico planning study was to evaluate the impact of dose escalation to the tumour regarding organs at risk (OARs) dose in nCRT for EC patients.Material and MethodsFor this study, we used the planning CT scans of 16 EC patients, who were treated with proton nCRT between April and July 2022 and who provided informed consent for the use of their data. The target dose was escalated from 41.4 Gy (current standard) to a total dose of 50.4 Gy by re-scaling the original clinical treatment plan. We investigated the impact of dose escalation on OARs dose for both the proton (IMPT) and the back-up photon (VMAT) plans, and differences in OARs dose were tested using the Wilcoxon signed rank test.ResultsFor both PhRT and PRT, the OARs dose increased significantly by escalating the dose to the target. In the escalated PhRT plans, the mean heart dose (MHD) and Lung V5 exceeded the constraints in 6 (37.5%) and 4 (25%) patients. None of the escalated PRT plans exceeded the normal tissue constraints. Only the left kidney dose was relatively high in 3 patients (mean 10-17 Gy). The absolute differences in OARs dose between the escalated and standard treatment plans were significantly higher in the PhRT plans as compared to the PRT plans. The MHD increased on average by 4.3 Gy, while in PRT the increase was only 1.9 Gy on average (Table 1). Moreover, the mean dose to heart and lungs remained significantly lower in the escalated proton plans compared to the non-escalated photon plans.ConclusionFrom a dosimetric point of view, it seems feasible to escalate the dose to the target from 41.4 Gy to 50.4 Gy using PRT. In the escalated PRT plans, the MHD and MLD dose remained on average significantly lower than the current standard PhRT plans and did not exceed any OARs constraints. Re-optimisation of the escalated treatment plans might reduce the OARs dose slightly. However, in PhRT the optimisation is restricted by the relatively high heart- and lung dose and its constraints

Determinants of adherence to physical cancer rehabilitation guidelines among cancer patients and cancer centers: a cross-sectional observational study

Purpose: To tailor implementation strategies that maximize adherence to physical cancer rehabilitation (PCR) guidelines, greater knowledge concerning determinants of adherence to those guidelines is needed. To this end, we assessed the determinants of adherence to PCR guidelines in the patient and cancer center. Methods: We investigated adherence variation of PCR guideline-based indicators regarding [1] screening with the Distress Thermometer (DT), [2] information provision concerning physical activity (PA) and physical cancer rehabilitation programs (PCRPs), [3] advice to take part in PA and PCRPs, [4] referral to PCRPs, [5] participation in PCRPs, and [6] PA uptake (PAU) in nine cancer centers. Furthermore, we assessed patient and cancer center characteristics as possible determinants of adherence. Regression analyses were used to determine associations between guideline adherence and patient and cancer center characteristics. In these analyses, we assumed the patient (level 1) nested within the cancer center (level 2). Results: Nine hundred and ninety-nine patients diagnosed with cancer between January 2014 and June 2015 were included. Of the 999 patients included in the study, 468 (47%) received screening with the DT and 427 (44%) received information provision concerning PA and PCRPs. Subsequently, 550 (56%) patients were advised to take part in PA and PCRPs, which resulted in 174 (18%) official referrals. Ultimately, 280 (29%) patients participated in PCRPs, and 446 (45%) started PAU. Screening with the DT was significantly associated with information provision concerning PA and PCRPs (OR 1.99, 95% CI 1.47–2.71), advice to take part in PA and PCRPs (OR 1.79, 95% CI 1.31–2.45), referral to PCRPs (OR 1.81, 95% CI 1.18–2.78), participation in PCRPs (OR 2.04, 95% CI 1.43–2.91), and PAU (OR 1.69, 95% CI 1.25–2.29). Younger age, male gender, breast cancer as the tumor type, ≥2 cancer treatments, post-cancer treatment weight gain/loss, employment, and fatigue were determinants of guideline adherence. Less variation in scores of the indicators between the different cancer centers was found. This variation between centers was too low to detect any association between center characteristics with the indicators. Conclusions: The implementation of PCR guidelines is in need of improvement. We found determinants at the patient level associated with guideline-based PCR care. Implications for Cancer Survivors: Implementation strategies that deal with the determinants of adherence to PCR guidelines might improve the implementation of PCR guidelines and the quality of life of cancer survivors

Value of Implementation of Strategies to Increase the Adherence of Health Professionals and Cancer Survivors to Guideline-Based Physical Exercise

Background: To increase the adherence of health professionals and cancer survivors to evidence-based physical exercise, effective implementation strategies (ISTs) are required. Objectives: To examine to what extent these ISTs provide value for money and which IST has the highest expected value. Methods: The net benefit framework of health economic evaluations is used to conduct a value-of-implementation analysis of nine ISTs. Seven are directed to health professionals and two to cancer survivors. The analysis consists of four steps: 1) analyzing the expected value of perfect implementation (EVPIM); 2) assessing the estimated costs of the various ISTs; 3) comparing the ISTs' costs with the EVPIM; and 4) assessing the total net benefit (TNB) of the ISTs. These steps are followed to identify which strategy has the greatest value. Results: The EVPIM for physical exercise in the Netherlands is €293 million. The total costs for the ISTs range from €34,000 for printed educational materials for professionals to €120 million for financial incentives for patients, and thus all are cost-effective. The TNB of the ISTs that are directed to professionals ranges from €5.7 million for printed educational materials to €30.9 million for reminder systems. Of the strategies that are directed to patients, only the motivational program had a positive net benefit of €100.4 million. Conclusions: All the ISTs for cancer survivors, except for financial incentives, had a positive TNB. The largest improvements in adherence were created by a motivational program for patients, followed by a reminder system for professionals

Implementing physical activity programs for patients with cancer in current practice: patients’ experienced barriers and facilitators

Purpose: The present study aimed to identify patients’ experienced barriers and facilitators in implementing physical activity programs for patients with cancer. Methods: We interviewed 34 patients in focus-group-interviews from three different hospital-types. We included patients with cancer who were either receiving curative treatment or had recently completed it. Barriers and facilitators were explored in six domains: (1) physical activity programs, (2) patients, (3) healthcare professionals (HCPs), (4) social setting, (5) organization, and (6) law and governance. Results: We found 12 barriers and 1 facilitator that affect the implementation of physical activity programs. In the domain of physical activity programs, the barrier was physical activity programs not being tailored to the patient’s needs. In the domain of patients, lacking responsibility for one’s own health was a barrier. Knowledge and skills for physical activity programs and non-commitment of HCPs impeded implementation in the domain of HCPs. Barriers in the domain of organization included inconvenient place, time of day, and point in the health treatment schedule for offering the physical activity programs, inadequate capacity, inaccessibility of contact persons, lack of information about physical activity programs, non-involvement of the general practitioner in the cancer care process, and poor communication between secondary and primary HCPs. Insufficient insurance-coverage of physical activity programs was a barrier in the domain of law and governance. In the domain of physical activity programs, contact with peers facilitated implementation. We found no barriers or facilitators at the social setting. Conclusions: Factors affecting the implementation of physical activity programs occurred in various domains. Most of the barriers occurred in the domain of organization. Implications for Cancer survivors: An implementation strategy that deals with the barriers might improve the implementation of physical activity programs and quality of life of cancer survivors