Translating Evidence from Dutch Exercise Oncology Trials in Patients with Breast Cancer into Clinical Practice Using the RE-AIM Framework

Purpose. We aimed to evaluate the potential for implementing exercise interventions for patients with breast cancer in the Netherlands, based on findings of the Dutch randomized controlled trials in this population. Methods. We evaluated the implementation of four Dutch exercise trials retrospectively, using the five dimensions of the RE-AIM framework: Reach (exercise participation rate), Effectiveness for physical fitness, fatigue, quality of life, and physical function, Adoption (e.g., satisfaction of physical therapists guiding the exercise intervention), Implementation (cost-effectiveness and exercise adherence correlates thereof), and Maintenance (maintenance of exercise levels by individual patients and sustainability of exercise delivery at organization level). Thereby, we reflect on these results using (international) literature to gain better insight in overall barriers, facilitators, and opportunities for further implementation of exercise interventions. Results. Participation rates of 44-52% not only indicated acceptable Reach in the context of a trial but also indicated room for improvement. Effectiveness of exercise during and after treatment was demonstrated in most trials showing benefits for aerobic fitness, physical fatigue, quality of life and physical function, and high patient satisfaction. Adoption of the exercise interventions by physical therapists was adequate (satisfaction score: 7.5 out of 10). Evaluation of Implementation indicated adequate adherence to supervised exercise, inconsistent findings on potential correlates of adherence, and promising results on cost-effectiveness. Currently, reimbursement for exercise programs is lacking. Maintenance of intervention effects at the patient level was limited and inconsistent. Maintenance of intervention availability at the organizational level was facilitated by an extensive network of specially trained physical therapists, but better communication and collaboration between different healthcare professionals are desired. Conclusions. Improved implementation could particularly be achieved by increasing reach and improved focus on exercise maintenance on both the patient and organizational level

Which are the best conservative interventions for lymphoedema after breast cancer surgery?

Lymphoedema is a common complication of breast cancer surgery with or without adjuvant cancer treatments.1 Fluid accumulates because of damage to the lymphatic system, most commonly after axillary lymph node dissection. Box 1 shows factors associated with lymphoedema. Swelling is commonly in the arm but can involve the chest or back; it can result in pain, dysfunction, and disturbance of body image

Education Needs of Dutch Physical Therapists for the Treatment of Patients With Advanced Cancer: A Mixed Methods Study

BACKGROUND: The survival rates for patients with advanced cancer have increased over time. Many patients experience symptoms and functional limitations that impair activities of daily living and limit quality of life. A number of these health problems are amenable to physical therapist treatment. However, physical therapists caring for patients with advanced cancer require special training and skills. OBJECTIVE: The study aimed to assess the educational needs and clinical uncertainties of Dutch physical therapists in relation to treatment of patients with advanced cancer. DESIGN: This was a mixed methods study. METHODS: A survey and 2 focus groups were conducted among physical therapists working in primary care who had previously received at least basic oncology training. RESULTS: A total of 162 physical therapists completed the survey. The most frequently reported educational needs were related to effective interprofessional collaboration (61.7%), knowledge of medical treatment (49.4%), and current evidence on physical therapist interventions in this population (49.4%). In the focus groups, physical therapists (n = 17) voiced uncertainties about treating patients with bone metastases, setting realistic goals, when and how to end a treatment episode, interprofessional collaboration, finding and using evidence, and using clinimetrics. CONCLUSION: These results support the need for specific education programs for physical therapists working with advanced cancer patients to increase the availability of high-quality oncology rehabilitation for this population

Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of developing lymphoedema after breast cancer therapy

Background Breast cancer-related lymphoedema can be a debilitating long-term sequela of breast cancer treatment. Several studies have investigated the effectiveness of different treatment strategies to reduce the risk of breast cancer-related lymphoedema. Objectives To assess the effects of conservative (non-surgical and non-pharmacological) interventions for preventing clinically-detectable upperlimb lymphoedema after breast cancer treatment. Search methods We searched theCochrane BreastCancerGroup's (CBCG) SpecialisedRegister, CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro, PsycINFO, and the World Health Organization (WHO) International Clinical Trials Registry Platform in May 2013. Reference lists of included trials and other systematic reviews were searched. Selection criteria Randomised controlled trials that reported lymphoedema as the primary outcome and compared any conservative intervention to either no intervention or to another conservative intervention. Data collection and analysis Three authors independently assessed the risk of bias and extracted data. Outcome measures included lymphoedema, infection, range of motion of the shoulder, pain, psychosocial morbidity, level of functioning in activities of daily life (ADL), and health-related quality of life (HRQoL). Where possible, meta-analyses were performed. Risk ratio (RRs) or hazard ratio (HRs) were reported for dichotomous outcomes or lymphoedema incidence, and mean differences (MDs) for range of motion and patient-reported outcomes. Main results Ten trials involving 1205 participants were included. The duration of patient follow-up ranged from 2 days to 2 years after the intervention. Overall, the quality of the evidence generated by these trials was low, due to risk of bias in the included trials and inconsistency in the results. Manual lymph drainage In total, four studies used manual lymph drainage (MLD) in combination with usual care or other interventions. In one study, lymphoedema incidence was lower in patients receiving MLD and usual care (consisting of standard education or exercise, or both) compared to usual care alone. A second study reported no difference in lymphoedema incidence when MLD was combined with physiotherapy and education compared to physiotherapy alone. Two other studies combiningMLDwith compression and scar massage or exercise observed a reduction in lymphoedema incidence compared to education only, although this was not significant in one of the studies. Two out of the four studies reported on shoulder mobility where MLD combined with exercise gave better shoulder mobility for lateral arm movement (shoulder abduction) and forward flexion in the first weeks after breast cancer surgery, compared to education only (mean difference for abduction 22 degrees; 95% confidence interval (CI) 14 to 30; mean difference for forward flexion 14 degrees; 95% CI 7 to 22). Two of the studies on MLD reported on pain, with inconsistent results. Results on HRQoL in two studies on MLD were also contradictory. Exercise: early versus delayed start of shoulder mobilising exercises Three studies examined early versus late start of postoperative shoulder exercises. The pooled relative risk of lymphoedema after an early start of exercises was 1.69 (95% CI 0.94 to 3.01, 3 studies, 378 participants). Shoulder forward flexion was better at one and sixmonths follow-up for participants who started early with mobilisation exercises compared to a delayed start (two studies), but no meta-analysis could be performed due to statistical heterogeneity. There was no difference in shoulder mobility or self-reported shoulder disability at 12 months follow-up (one study). One study evaluated HRQoL and reported difference at one year follow-up (mean difference 1.6 points, 95% CI -2.14 to 5.34, on the Trial Outcome Index of the FACT-B). Two studies collected data on wound drainage volumes and only one study reported higher wound drainage volumes in the early exercise group. Exercise: resistance training Two studies compared progressive resistance training to restricted activity. Resistance training after breast cancer treatment did not increase the risk of developing lymphoedema (RR 0.58; 95% CI 0.30 to 1.13, two studies, 358 participants) provided that symptoms are monitored and treated immediately if they occur. One out of the two studies measured pain where participants in the resistance training group reported pain more often at three months and six months compared to the control group. One study reported HRQoL and found no significant difference between the groups. Patient education, monitoring and early intervention One study investigated the effects of a comprehensive outpatient follow-up programme, consisting of patient education, exercise, monitoring of lymphoedema symptoms and early intervention for lymphoedema, compared to education alone. Lymphoedema incidence was lower in the comprehensive outpatient follow-up programme (at any time point) compared to education alone (65 people). Participants in the outpatient follow-up programme had a significantly faster recovery of shoulder abduction compared to the education alone group. Authors' conclusions Based on the current available evidence, we cannot draw firm conclusions about the effectiveness of interventions containing MLD. The evidence does not indicate a higher risk of lymphoedema when starting shoulder-mobilising exercises early after surgery compared to a delayed start (i. e. seven days after surgery). Shoulder mobility (that is, lateral arm movements and forward flexion) is better in the short term when starting shoulder exercises earlier compared to later. The evidence suggests that progressive resistance exercise therapy does not increase the risk of developing lymphoedema, provided that symptoms are closely monitored and adequately treated if they occur. Given the degree of heterogeneity encountered, limited precision, and the risk of bias across the included studies, the results of this review should be interpreted with cautio

Tailoring of exercise and dietary interventions to adverse effects and existing comorbidities in patients with ovarian cancer receiving chemotherapy: a clinical vignettes study among expert physical therapists and dietitians

This study aims to capture the complex clinical reasoning process during tailoring of exercise and dietary interventions to adverse effects and comorbidities of patients with ovarian cancer receiving chemotherapy. Clinical vignettes were presented to expert physical therapists (n = 4) and dietitians (n = 3). Using the think aloud method, these experts were asked to verbalize their clinical reasoning on how they would tailor the intervention to adverse effects of ovarian cancer and its treatment and comorbidities. Clinical reasoning steps were categorized in questions raised to obtain additional information; anticipated answers; and actions to be taken. Questions and actions were labeled according to the evidence-based practice model. Questions to obtain additional information were frequently related to the patients’ capacities, safety or the etiology of health issues. Various hypothetical answers were proposed which led to different actions. Suggested actions by the experts included extensive monitoring of symptoms and parameters, specific adaptations to the exercise protocol and dietary-related patient education. Our study obtained insight into the complex process of clinical reasoning, in which a variety of patient-related variables are used to tailor interventions. This insight can be useful for description and fidelity assessment of interventions and training of healthcare professionals. The delivery of exercise and dietary programs is not a one-size fits all approach but involves a complex clinical reasoning process. Therefore, protocols should not only describe the intervention content, but also the strategy on how to tailor the intervention to individual adverse effects and pre-existing comorbidities. Education of healthcare professionals delivering the intervention is important as these professionals need to have good clinical reasoning skills to adequately tailor the intervention.</p