Curr Oncol, Vol. 21, pp. 267-271; doi: http://dx.doi.org/10.3747/co.21.2079
S H O RT C O M M U N I C A T I O N
Design and implementation of a community-based exercise program for breast cancer patients H .J. L ea ch P h D * J.M . D a n ylu k a n d S.N. C ulos—R e e d P hD *1? ABSTRACT R esearch has in d icated th at exercise is critical in the re co v ery p ro cess for b reast cancer p atients, and yet th is ev id en ce h as in freq u en tly b een tran slated into sustainable co m m u n ity program m ing. T he present ar ticle describes the p rocesses and operations o f b e a u t y (the B reast C an cer P atients E n g ag in g in A ctivity and U n d e rg o in g T re a tm e n t p ro g ram ). T h is e v id e n c e b ased 12-w eek exercise pro g ram , w ith an optional 12-week m ain ten an ce com ponent, is supported by the W in g s o f H ope F o u ndation, allow ing the p ro g ram to be delivered at no cost to participants. T he program w as d esig n ed to resto re an d im prove the physical w ell-b ein g o f w o m en living w ith b re ast ca n c e r as th ey u n d erg o chem otherapy o r ra d iatio n treatm ents. E valuations m easu re safety and adherence to the p ro g ram and the effects o f the program on physiologic and psychological outcom es and quality o f life. T he b e a u t y p ro g ram ad d resses the gap b etw een the level o f ev idence for the benefits o f exercise afte r a cancer diag n o sis and tran slatio n o f th at evidence into com m u n ity p ro g ra m m in g by p ro v id in g an accessible, in d ividualized, and safe physical activity program for w om en d u rin g treatm en t for b reast cancer.
KEYWORDS B reast cancer, com m unity, exercise, physical activity
1. INTRODUCTION A diagnosis o f breast cancer often requires extensive m edical in tervention that can take a significant toll on health, w ell-being, and overall quality o f life. Research has indicated th at exercise is critical in the recovery p ro cess for b reast cancer patients and can be used to m anage the negative side effects o f treatm ents, to in crease treatm ent com pletion rates, to im prove physical and psychological outcom es, and to enhance overall quality o f life1,2. Exercise for breast cancer patients and su rv iv o rs is not only efficacious, but safe as w ell3,4. A review o f ran d o m ized controlled trials for exercise
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interventions in b reast cancer survivors supports the safety o f card io resp irato ry exercise, stren g th tra in ing, and flex ib ility a c tiv ities5. R ecen t stu d ies also indicate that exercise afte r a b reast cancer diagnosis can significantly low er the chance o f recu rren ce and im prove survival rates6. Exercise clearly plays a crucial role in b reast can cer survivorship, and yet few er than 22% o f C anad ian cancer survivors rep o rt bein g active7. T his low p ro portion m ight reflect the fact that, despite convincing evidence for the efficacy o f exercise in intervention trials, th at evidence has b een infrequently tran slated into sustainable com m unity p ro g ram m in g for breast cancer survivors8. W h ite and colleagues8 identified this gap in the literature, noting that although exercise interventions have b een show n to b e beneficial a fte r a breast cancer diagnosis, the extent to w hich success ful interventions can be translated into sustainable exercise program s is unclear8. C om m unity-based exercise program s for cancer survivors have b ee n d escrib ed in the scientific lit erature9”13, but none have specifically targeted breast cancer patients currently undergoing treatm ent. R an dom ized controlled trials and qualitative research have found exercise during treatm ent for breast cancer to be safe and beneficial1, and a recent study suggests that it is im portant to begin an exercise program w ith breast cancer survivors at the beg in n in g o f chem otherapy treatm ent14. T hat tim ing presents a potential “teachable m om ent” in w hich w om en m ight be m ore am enable to m aking significant health behaviour changes and inter ested in finding w ays to take control o f their lives15,16. T he present article describes the processes and operations o f a free, not-for-profit com m unity-based exercise program for w om en undergoing chem other apy or radiation treatm ents for breast cancer.
2.
METHODS AND RESULTS
2.1 Program Design and Description T he B reast C ancer Patients Engaging in A ctivity and U ndergoing Treatm ent ( b e a u t y ) program com m enced
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in A ugust 2011. T his com m unity program has been o perating in the H ealth and W ellness L ab at the U ni versity o f C algary, C algary, A lb erta for m ore than 2 years. T he goals o f b e a u t y are to use exercise and education to restore and im prove the physical w ell b eing o f w om en living w ith breast cancer w hile on treatm ent; to increase aw areness o f the im portance o f healthy lifestyle behaviors; and to provide p ra cti cal tools and a variety o f resources to assist w om en in actively tak in g charge o f th eir health, fitness, and well-being. The 12-week b e a u t y exercise program also has an optional 12-week m aintenance com ponent and is o ffered at no cost to participants.
A ll q u estio n n aire s have b een te ste d for relia b ility and v alid ity in the ca n cer population. N ext, the c e p p erfo rm s a b aseline physical fitness assessm ent, follow ing co m p o n en ts o f the C anadian P h y sic a l A ctivity, F itn e ss a n d L ife sty le A p p ro a ch m an u al and o th er v alid ated protocols ou tlin ed b y the A m eric an C ollege o f S ports M edicine. A ll q u estio n n aires an d physical assessm en ts are re p eated at 12 w eeks and 24 w eeks, to g eth er w ith a 13-item (L ik ert scale and short-answ er) evaluation form to ev alu ate p artic ip a n t satisfactio n w ith the program .
2.2 Participant Referral and Eligibility
P a r tic ip a n ts a re p ro v id e d w ith a n in d iv id u a lly ta ilo re d ex e rcise p ro g ra m , b ase d on th e b a se lin e physical fitness assessm en t re su lts and th e ir exercise and m edical history. T h e exercise p ro g ra m inclu d es 2 d ay s o f aero b ic ex e rcise, 1 d ay o f re sista n c e ex er cise, a n d 5—7 d ay s o f flex ib ility ex e rcises p e r w eek. T h e c e p p ro v id es th e p a rtic ip a n t w ith 3 levels o f d iffic u lty for th e ir p ro g ra m (easiest, m ed iu m , and h a rd e r— flagged u sin g a red -, yellow -, a n d g re en lig h t stru c tu re ) so th a t th e p a rtic ip a n t c a n ta ilo r a n y giv en d a y ’s a c tiv ity to th e ir e n e rg y o r fa tig u e level. T able i show s an ex a m p le o f th e tie re d ex er cise p ro g ram . P articipants have the option o f centre- or hom ebased w orkouts. C entre w orkouts are group exercise sessions that are held at the u n iv ersity ’s T h riv e C en tre, a free exercise facility for can cer survivors. A resource package given to each particip an t contains pictures and descriptions o f all exercises to facilitate the hom e-based option. To enhance adheren ce to the hom e-based exercise prescription, participants are also asked to use a fitness log to track th eir w eekly activity.
P a rtic ip a n ts a re re fe rre d to th e b e a u t y p ro g ra m th ro u g h m u ltip le sources, in clu d in g the B reast C an ce r S u p p o rtiv e C are F oundation (http ://b cscf.co m ) and th e b re ast tu m o u r g roup at the Tom B ak er C a n ce r C en tre, w ho provide in fo rm atio n about the p ro g ram p rim arily in the form o f brochures. P articipants c a n also self-refer (that is, call o r sen d an e-m ail m essag e to th e b e a u t y p ro g ram sta ff) a fte r en c o u n terin g p o sters, b rochures, or inform ation at education sessions d eliv ered at the Tom B ak er C an ce r C entre. B reast ca n c e r su rv iv o rs m ig h t also co n tact b e a u t y s ta f f a fte r e n c o u n te rin g b ro c h u re s sen t to ca n c e r s u p p o rtiv e s e rv ic e s su ch as W e llsp rin g C a lg a ry (h ttp ://w w w .w e llsp rin g c alg ary .ca), C o m p assio n ate B eau ty (h ttp ://w w w .com passionatebeauty.com ), and R e th in k B reast C an cer C alg ary (http://w w w .rethinkb re astcan c er.co m ). M an y d efin itio n s fo r “c a n c e r su rv iv o r” exist; w e u n d e rsta n d the te rm to m ean “ fro m the p o in t o f d iag n o sis to en d -o f-life” 17. H ow ever, to be eligible for th e b e a u t y p ro g ram , w om en m u st c u rren tly be u n d erg o in g ch e m o th erap y o r ra d ia tio n tre a tm e n t for b re ast ca n c e r o r m u st be w ith in 3 m onths o f com plet ing treatm en t. W om en m u st also be m ore th a n 18 y ea rs o f age, be able to sp ea k an d re a d E n g lish , be m ed ically stable en o u g h to p artic ip a te in exercise, an d be w illin g to atten d the p ro g ram and its asso c i ated asse ssm e n ts at the U n iv ersity o f C algary.
2.3 Beginning the Program A fte r eligibility is confirm ed, p articip an ts have a first ap p o in tm en t w ith a C an ad ia n S ociety for E xercise P h y sio lo g y —c e rtified exercise p h y sio lo g ist ( c e p ) at th e T h riv e E x ercise L a b o ra to ry at th e U n iv ersity o f C algary. D u rin g th at visit, p artic ip a n ts com plete fo rm s th at include in fo rm ed co n sen t to p articip ate, d em o g rap h ic d etails, and exercise and m ed ical h is to ry (in clu d in g d etailed in fo rm atio n p e rta in in g to th e ir ca n c e r d iag n o sis, trea tm e n t, an d side effects). P articip an ts th en com plete a series o f q u estio n n aires th at m easu re h ea lth -related q u ality o f life, fatigue, co g n itiv e fu n c tio n , an d d ep ressiv e sy m p to m s18,19.
2.4 Exercise Program Development
2.5 Education Sessions In a d d itio n to th e ex ercise p ro g ra m m in g , b e a u t y includes ed u catio n sessions delivered by a v arie ty o f ex p e rts ev ery second w eek d u rin g the pro g ram . T he sessions are desig n ed to educate, in fo rm , and em p o w er p artic ip a n ts to ad o p t a h e a lth ie r lifestyle. T h ey provide in fo rm atio n about topics such as goal setting, principles o f exercise, physical and psy ch o so cial b enefits o f exercise, n u tritio n , sleep and fatig u e, stress m an ag em en t, social su p p o rt, an d b ra in fog.
2.6 Funding and Sustainability T he b e a u t y pro g ram has been successful in deliver ing a physical activity p ro g ram for w om en w ho are undergoing treatm en t for breast cancer. S ustain in g a safe, efficacious and cost-effective com m un ity -b ased exercise p ro g ram for breast cancer survivors such as b e a u t y poses m any challenges, the greatest o f w hich is probably finding the funds n ecessary to cover the overhead costs o f ru n n in g the program . C urrently,
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COMMUNITY PHYSICAL ACTIVITY PROGRAM FOR BREAST CANCER PATIENTS
b e a u t y is fu n d e d b y the W ings o f H ope F oundation, a n o n p ro fit, v o lu n te e r-ru n fu n d ra is in g in itia tiv e th at p ro v id es fin an cial assistan ce to b re ast ca n cer p atien ts and th at su p p o rts o th er in itiativ es designed to help w o m en heal from b re ast cancer. T h is fu n d ing allow s th e p ro g ram to b e delivered at no cost to p a rtic ip a n ts, w h ich sig n ifican tly and positively affects recru itm en t. S u sta in ab ility o f the p ro g ram dep en d s no t only on co n tin u ed fu n d in g , bu t also on co o p eratio n and c o lla b o ra tio n w ith lo cal d o c to rs , a re a h o sp ita ls, ca n cer cen tres, and o th er c o m m u n ity o rganizations. R e fe rra l by h ea lth ca re p ro v id e rs to th e ex e rcise p ro g ram plays a critical role in the re c ru itm e n t p ro ce ss10,20; how ever, m an y o n co lo g ists re p o rt in su f ficient tim e to d iscu ss exercise p ro g ra m m in g w ith p atien ts21. E x istin g p artn e rsh ip s th at have helped the su stain ab ility o f b e a u t y include those w ith the Tom B ak er C an ce r C en tre, the B reast C an ce r S upportive C are F o u n d atio n , and W ellspring C algary.
2.7 Evaluation P ro g ra m su c c e ss is m e a s u re d as re c ru itm e n t into th e p ro g ra m , p a rtic ip a n t-re p o rte d satisfa c tio n w ith
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th e p ro g ra m , a n d m a in te n a n c e o r im p ro v e m e n ts in f a tig u e , h e a lt h - r e l a t e d q u a l i t y o f lif e , a n d p h y sic a l fitn e ss o u tc o m e s. In te rm s o f im m e d ia te im p a c t, all in fo rm a tio n c o lle c te d fo r p h y sic a l and p a tie n t-re p o rte d o u tc o m e s fe ed s d ire c tly b a c k to th e p a rtic ip a n ts , m o tiv a tin g th e m to m a in ta in a re g u la r p ro g ra m o f p h y sic a l a c tiv ity . T h e p a r tic i p a n ts in th e p ro g ra m have re c e n tly b e e n d ia g n o se d w ith b re a s t c a n c e r, a n d th e p ro g ra m h o p e s to f u l fil th e ir n e e d fo r in fo rm a tio n a n d to h e lp th e m re g a in so m e c o n tro l o v e r th e ir liv es d u rin g th e p o s t-d ia g n o s is p e r io d 16. T h e b e a u t y p ro g ra m is o n g o in g a n d th e re fo re is c o n tin u a lly b e in g re fin e d in r e g u la r q u a lity im p ro v em en t cycles. A n a ly se s are c u rre n tly u n d e r w ay to evaluate the program , and w ill utilize elem ents o f th e r e - a i m (R e a c h - E f f e c tiv e n e s s - A d o p tio n Im p le m e n ta tio n -M a in te n a n c e ) fra m e w o rk (h ttp :// w w w .re -a im .h n f e .v t.e d u /). T ab le n o u tlin e s th e p a ra m e te rs o f th e b e a u t y p ro g ra m th a t w e in te n d to e v a lu a te u sin g r e - a i m . L esso n s le a rn e d fro m the e v a lu a tio n o f b e a u t y w ill c o n trib u te to c o n tin u o u s q u a lity im p ro v e m e n t o f th e p ro g ra m a n d to th e g ro w th o f th e p ro g ra m in to a su sta in a b le c o m m u n ity re so u rc e .
Tiered exercise prescription for the beauty program
Exercise category
Red light (easiest)
Yellow light (moderate)
Green light (hardest)
Aerobic0
Heart rate should reach 40%-60% of age-predicted maximum, with a rated perceived exertion of 1-3, for 20-60 minutes
Heart rate should reach 40%-60% of age-predicted maximum, with a rated perceived exertion of 1-3, for 20-60 minutes
Heart rate should reach 40%-60% of age-predicted maximum, with a rated perceived exertion of 1-3, for 20-60 minutes
Resistance
1-2 sets, 8-12 repetitions, 5 exercises
1-3 sets, 8-12 repetitions, 7-8 exercises
2-3 sets, 8-12 repetitions, 10-14 exercises
Flexibility
5-7 days per week
5-7 days per week
5-7 days per week
Participants are instructed to adjust their heart rate, rating of perceived exertion, and exercise duration based on their perceived energy and fatigue on any given day (for example, a “green” day might mean reaching 60% of maximum heart rate for 60 minutes at a rated perceived exertion of 3, and a “red” day might mean exercising for 10 minutes at a time and reaching 40% of maximum heart rate at a rated perceived exertion of 1).
table
n Reach-Effectiveness-Adoption-Implementation-Maintenance (r e - aim ) evaluation of the beauty program Reach
Enrollment Annual enrollment compared with estimated number of breast cancer diagnoses in Calgary annually Representativeness Demographics of participants compared with demographics of women diagnosed with breast cancer in the Calgary area
Effectiveness
Adoption
Psychosocial Adherence and physiologic Attendance at centre exercise outcomes at sessions and self-reported 12 and 24 weeks compliance with home exercise Retention Completion of 12-week or 24-week assessment (or both)
Implementation
Maintenance
Safety of the Cost to run the program, defined program per as the number of participant adverse events Participant exercise reported behavior 6 months after program completion
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3. DISCUSSION AND CONCLUSIONS The beauty exercise program provides an ongoing and extrem ely im portant resource for w om en w ith breast cancer. A fter diagnosis, breast cancer patients and survivors need access to a supportive and safe exercise environm ent that is led by professionals w ith relevant cancer-specific training and that tar gets key concerns com m only seen in survivors (that is, fatigue, negative changes in body composition, physical functioning, and health-related quality of life). Given the im m ensely positive effect that exer cise can have not only on physical and psychosocial outcom es, but also on recurrence and survival rates, the im portance o f offering an evidence-based com m unity exercise program for this population cannot be underestim ated. T he beauty p ro g ra m a d d re sse s the gap b e tw e e n the level o f e v id e n c e for the benefits o f exercise a fte r a cancer diagnosis and tran slatio n to co m m u n ity p ro g ra m m in g 8. It is designed to oper ate in a “real-w orld” setting, em phasizing external validity and generalizability beyond the population o f an intervention or a random ized controlled trial. T his p rogram m odel, w hich is designed for b reast cancer patients who are currently undergoing treat m ent, has, like o ther com m u n ity -b ased physical a c tiv ity p ro g ra m s for c a n c e r su rv iv o rs 9" 13, the poten tial to in sp ire long-term behavioural change and to have a trem en d o u s positive im pact on the b reast c an cer com m unity.
4. ACKNOWLEDGMENTS The authors thank W ings o f Hope for their contribu tions to the beauty program
5. CONFLICT OF INTEREST DISCLOSURES The authors have no financial conflicts o f interest to declare.
6. REFERENCES 1. Courneya KS, Segal RJ, Mackey JR, et al. Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol 2007;25:4396-404. 2. McNeely ML, Campbell KL, Rowe BH, Klassen TP, Mackey JR, Courneya KS. Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis. CMAJ 2006;175:34-41. 3. Fong DY, Ho JW, Hui BP, et al. Physical activity for cancer survivors: meta-analysis of randomised controlled trials. BMJ 2012;344:e70. 4. Speck RM, Courneya KS, Masse LC, Duval S, Schmitz KH. An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv 2010;4:87-100.
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5. Schmitz KH, Speck RM. Risks and benefits of physical activity among breast cancer survivors who have completed treatment. Womens Health (Lond Engl) 2010;6:221-38. 6. Ibrahim EM, Al-Homaidh A. Physical activity and survival after breast cancer diagnosis: meta-analysis of published stud ies. Med Oncol 2011;28:753-65. 7. Courneya KS, Katzmarzyk PT, Bacon E. Physical activity and obesity in Canadian cancer survivors: population-based estimates from the 2005 Canadian Community Health Survey. Cancer 2008;112:2475-82. 8. White SM, McAuley E, Estabrooks PA, Courneya KS. Translating physical activity interventions for breast cancer survivors into practice: an evaluation of randomized controlled trials. Ann Behav Med 2009;37:10-19. 9. Cheifetz O, Park Dorsay J, Hladysh G, Macdermid J, Serediuk F, Woodhouse LJ. CanWell: meeting the psychosocial and exercise needs of cancer survivors by translating evidence into practice. Psychooncology 2014;23:204-15. 10. Haas BK, Kimmel G. Model for a community-based exercise program for cancer survivors: taking patient care to the next level. J Oncol Pract 2011;7:252-6. 11. Knobf MT, Thompson AS, Fennie K, Erdos D. The effect of a community-based exercise intervention on symptoms and quality of life. Cancer Nurs 2014;37:E43-50. 12. Noble M, Russell C, Kraemer L, Sharratt M. uw w el l -f it : the impact of supervised exercise programs on physical capac ity and quality of life in individuals receiving treatment for cancer. Support Care Cancer 2012;20:865-73. 13. Rajotte EJ, Yi JC, Baker KS, Gregerson L, Leiserowitz A, Syrjala KL. Community-based exercise program effec tiveness and safety for cancer survivors. J Cancer Surviv 2012;6:219-28. 14. Chou FY, Dodd MJ, Paul SM. Timing and sustainability of an exercise intervention in women with breast cancer during and after cancer treatment. Oncol Nurs Forum 2012;39:91-7. 15. Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol 2005;23:5814-30. 16. McCaughan E, McKenna H. Never-ending making sense: towards a substantive theory of the information-seeking behaviour of newly diagnosed cancer patients. J Clin Nurs 2007;16:2096-104. 17. Ristovski-Slijepcevic S. Environmental Scan o f Cancer Survivorship in Canada: Conceptualization, Practice and Research. Vancouver, BC: Sociobehavioural Research Centre, BC Cancer Agency; 2008. 18. Webster K, Celia D, Yost K. The Functional Assessment of Chronic Illness Therapy (fa c it ) measurement system: properties, applications, and interpretation. Health Qual Life Outcomes 2003;1:79. 19. Radloff LS. The c es - d scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385-401. 20. Jones LW, Courneya KS, Fairey AS, Mackey JR. Effects of an oncologist’s recommendation to exercise on self-reported exercise behavior in newly diagnosed breast cancer survivors: a single-blind, randomized controlled trial. Ann Behav Med 2004;28:105-13.
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21. Peeters C, Stewart A, Segal R, Wouterloot E, Scott CG, Aubry T. Evaluation of a cancer exercise program: patient and physi cian beliefs. Psychooncology 2009;18:898-902.
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Correspondence to: S. Nicole C ulos-R eed, 2500 Uni versity Drive NW, Calgary, A lberta T2N 1N4. E -m ail: nculosre@ ucalgary.ca
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Faculty o f Kinesiology, U niversity o f Calgary, Calgary, AB. D ep artm en t o f Psychosocial R esources, Tom B aker C ancer Centre, Calgary, AB. D epartm ent o f Oncology, Faculty o f M edicine, U niversity o f Calgary, Calgary, AB.
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S H O RT C O M M U N I C A T I O N
Design and implementation of a community-based exercise program for breast cancer patients H .J. L ea ch P h D * J.M . D a n ylu k a n d S.N. C ulos—R e e d P hD *1? ABSTRACT R esearch has in d icated th at exercise is critical in the re co v ery p ro cess for b reast cancer p atients, and yet th is ev id en ce h as in freq u en tly b een tran slated into sustainable co m m u n ity program m ing. T he present ar ticle describes the p rocesses and operations o f b e a u t y (the B reast C an cer P atients E n g ag in g in A ctivity and U n d e rg o in g T re a tm e n t p ro g ram ). T h is e v id e n c e b ased 12-w eek exercise pro g ram , w ith an optional 12-week m ain ten an ce com ponent, is supported by the W in g s o f H ope F o u ndation, allow ing the p ro g ram to be delivered at no cost to participants. T he program w as d esig n ed to resto re an d im prove the physical w ell-b ein g o f w o m en living w ith b re ast ca n c e r as th ey u n d erg o chem otherapy o r ra d iatio n treatm ents. E valuations m easu re safety and adherence to the p ro g ram and the effects o f the program on physiologic and psychological outcom es and quality o f life. T he b e a u t y p ro g ram ad d resses the gap b etw een the level o f ev idence for the benefits o f exercise afte r a cancer diag n o sis and tran slatio n o f th at evidence into com m u n ity p ro g ra m m in g by p ro v id in g an accessible, in d ividualized, and safe physical activity program for w om en d u rin g treatm en t for b reast cancer.
KEYWORDS B reast cancer, com m unity, exercise, physical activity
1. INTRODUCTION A diagnosis o f breast cancer often requires extensive m edical in tervention that can take a significant toll on health, w ell-being, and overall quality o f life. Research has indicated th at exercise is critical in the recovery p ro cess for b reast cancer patients and can be used to m anage the negative side effects o f treatm ents, to in crease treatm ent com pletion rates, to im prove physical and psychological outcom es, and to enhance overall quality o f life1,2. Exercise for breast cancer patients and su rv iv o rs is not only efficacious, but safe as w ell3,4. A review o f ran d o m ized controlled trials for exercise
M K in*
interventions in b reast cancer survivors supports the safety o f card io resp irato ry exercise, stren g th tra in ing, and flex ib ility a c tiv ities5. R ecen t stu d ies also indicate that exercise afte r a b reast cancer diagnosis can significantly low er the chance o f recu rren ce and im prove survival rates6. Exercise clearly plays a crucial role in b reast can cer survivorship, and yet few er than 22% o f C anad ian cancer survivors rep o rt bein g active7. T his low p ro portion m ight reflect the fact that, despite convincing evidence for the efficacy o f exercise in intervention trials, th at evidence has b een infrequently tran slated into sustainable com m unity p ro g ram m in g for breast cancer survivors8. W h ite and colleagues8 identified this gap in the literature, noting that although exercise interventions have b een show n to b e beneficial a fte r a breast cancer diagnosis, the extent to w hich success ful interventions can be translated into sustainable exercise program s is unclear8. C om m unity-based exercise program s for cancer survivors have b ee n d escrib ed in the scientific lit erature9”13, but none have specifically targeted breast cancer patients currently undergoing treatm ent. R an dom ized controlled trials and qualitative research have found exercise during treatm ent for breast cancer to be safe and beneficial1, and a recent study suggests that it is im portant to begin an exercise program w ith breast cancer survivors at the beg in n in g o f chem otherapy treatm ent14. T hat tim ing presents a potential “teachable m om ent” in w hich w om en m ight be m ore am enable to m aking significant health behaviour changes and inter ested in finding w ays to take control o f their lives15,16. T he present article describes the processes and operations o f a free, not-for-profit com m unity-based exercise program for w om en undergoing chem other apy or radiation treatm ents for breast cancer.
2.
METHODS AND RESULTS
2.1 Program Design and Description T he B reast C ancer Patients Engaging in A ctivity and U ndergoing Treatm ent ( b e a u t y ) program com m enced
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in A ugust 2011. T his com m unity program has been o perating in the H ealth and W ellness L ab at the U ni versity o f C algary, C algary, A lb erta for m ore than 2 years. T he goals o f b e a u t y are to use exercise and education to restore and im prove the physical w ell b eing o f w om en living w ith breast cancer w hile on treatm ent; to increase aw areness o f the im portance o f healthy lifestyle behaviors; and to provide p ra cti cal tools and a variety o f resources to assist w om en in actively tak in g charge o f th eir health, fitness, and well-being. The 12-week b e a u t y exercise program also has an optional 12-week m aintenance com ponent and is o ffered at no cost to participants.
A ll q u estio n n aire s have b een te ste d for relia b ility and v alid ity in the ca n cer population. N ext, the c e p p erfo rm s a b aseline physical fitness assessm ent, follow ing co m p o n en ts o f the C anadian P h y sic a l A ctivity, F itn e ss a n d L ife sty le A p p ro a ch m an u al and o th er v alid ated protocols ou tlin ed b y the A m eric an C ollege o f S ports M edicine. A ll q u estio n n aires an d physical assessm en ts are re p eated at 12 w eeks and 24 w eeks, to g eth er w ith a 13-item (L ik ert scale and short-answ er) evaluation form to ev alu ate p artic ip a n t satisfactio n w ith the program .
2.2 Participant Referral and Eligibility
P a r tic ip a n ts a re p ro v id e d w ith a n in d iv id u a lly ta ilo re d ex e rcise p ro g ra m , b ase d on th e b a se lin e physical fitness assessm en t re su lts and th e ir exercise and m edical history. T h e exercise p ro g ra m inclu d es 2 d ay s o f aero b ic ex e rcise, 1 d ay o f re sista n c e ex er cise, a n d 5—7 d ay s o f flex ib ility ex e rcises p e r w eek. T h e c e p p ro v id es th e p a rtic ip a n t w ith 3 levels o f d iffic u lty for th e ir p ro g ra m (easiest, m ed iu m , and h a rd e r— flagged u sin g a red -, yellow -, a n d g re en lig h t stru c tu re ) so th a t th e p a rtic ip a n t c a n ta ilo r a n y giv en d a y ’s a c tiv ity to th e ir e n e rg y o r fa tig u e level. T able i show s an ex a m p le o f th e tie re d ex er cise p ro g ram . P articipants have the option o f centre- or hom ebased w orkouts. C entre w orkouts are group exercise sessions that are held at the u n iv ersity ’s T h riv e C en tre, a free exercise facility for can cer survivors. A resource package given to each particip an t contains pictures and descriptions o f all exercises to facilitate the hom e-based option. To enhance adheren ce to the hom e-based exercise prescription, participants are also asked to use a fitness log to track th eir w eekly activity.
P a rtic ip a n ts a re re fe rre d to th e b e a u t y p ro g ra m th ro u g h m u ltip le sources, in clu d in g the B reast C an ce r S u p p o rtiv e C are F oundation (http ://b cscf.co m ) and th e b re ast tu m o u r g roup at the Tom B ak er C a n ce r C en tre, w ho provide in fo rm atio n about the p ro g ram p rim arily in the form o f brochures. P articipants c a n also self-refer (that is, call o r sen d an e-m ail m essag e to th e b e a u t y p ro g ram sta ff) a fte r en c o u n terin g p o sters, b rochures, or inform ation at education sessions d eliv ered at the Tom B ak er C an ce r C entre. B reast ca n c e r su rv iv o rs m ig h t also co n tact b e a u t y s ta f f a fte r e n c o u n te rin g b ro c h u re s sen t to ca n c e r s u p p o rtiv e s e rv ic e s su ch as W e llsp rin g C a lg a ry (h ttp ://w w w .w e llsp rin g c alg ary .ca), C o m p assio n ate B eau ty (h ttp ://w w w .com passionatebeauty.com ), and R e th in k B reast C an cer C alg ary (http://w w w .rethinkb re astcan c er.co m ). M an y d efin itio n s fo r “c a n c e r su rv iv o r” exist; w e u n d e rsta n d the te rm to m ean “ fro m the p o in t o f d iag n o sis to en d -o f-life” 17. H ow ever, to be eligible for th e b e a u t y p ro g ram , w om en m u st c u rren tly be u n d erg o in g ch e m o th erap y o r ra d ia tio n tre a tm e n t for b re ast ca n c e r o r m u st be w ith in 3 m onths o f com plet ing treatm en t. W om en m u st also be m ore th a n 18 y ea rs o f age, be able to sp ea k an d re a d E n g lish , be m ed ically stable en o u g h to p artic ip a te in exercise, an d be w illin g to atten d the p ro g ram and its asso c i ated asse ssm e n ts at the U n iv ersity o f C algary.
2.3 Beginning the Program A fte r eligibility is confirm ed, p articip an ts have a first ap p o in tm en t w ith a C an ad ia n S ociety for E xercise P h y sio lo g y —c e rtified exercise p h y sio lo g ist ( c e p ) at th e T h riv e E x ercise L a b o ra to ry at th e U n iv ersity o f C algary. D u rin g th at visit, p artic ip a n ts com plete fo rm s th at include in fo rm ed co n sen t to p articip ate, d em o g rap h ic d etails, and exercise and m ed ical h is to ry (in clu d in g d etailed in fo rm atio n p e rta in in g to th e ir ca n c e r d iag n o sis, trea tm e n t, an d side effects). P articip an ts th en com plete a series o f q u estio n n aires th at m easu re h ea lth -related q u ality o f life, fatigue, co g n itiv e fu n c tio n , an d d ep ressiv e sy m p to m s18,19.
2.4 Exercise Program Development
2.5 Education Sessions In a d d itio n to th e ex ercise p ro g ra m m in g , b e a u t y includes ed u catio n sessions delivered by a v arie ty o f ex p e rts ev ery second w eek d u rin g the pro g ram . T he sessions are desig n ed to educate, in fo rm , and em p o w er p artic ip a n ts to ad o p t a h e a lth ie r lifestyle. T h ey provide in fo rm atio n about topics such as goal setting, principles o f exercise, physical and psy ch o so cial b enefits o f exercise, n u tritio n , sleep and fatig u e, stress m an ag em en t, social su p p o rt, an d b ra in fog.
2.6 Funding and Sustainability T he b e a u t y pro g ram has been successful in deliver ing a physical activity p ro g ram for w om en w ho are undergoing treatm en t for breast cancer. S ustain in g a safe, efficacious and cost-effective com m un ity -b ased exercise p ro g ram for breast cancer survivors such as b e a u t y poses m any challenges, the greatest o f w hich is probably finding the funds n ecessary to cover the overhead costs o f ru n n in g the program . C urrently,
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b e a u t y is fu n d e d b y the W ings o f H ope F oundation, a n o n p ro fit, v o lu n te e r-ru n fu n d ra is in g in itia tiv e th at p ro v id es fin an cial assistan ce to b re ast ca n cer p atien ts and th at su p p o rts o th er in itiativ es designed to help w o m en heal from b re ast cancer. T h is fu n d ing allow s th e p ro g ram to b e delivered at no cost to p a rtic ip a n ts, w h ich sig n ifican tly and positively affects recru itm en t. S u sta in ab ility o f the p ro g ram dep en d s no t only on co n tin u ed fu n d in g , bu t also on co o p eratio n and c o lla b o ra tio n w ith lo cal d o c to rs , a re a h o sp ita ls, ca n cer cen tres, and o th er c o m m u n ity o rganizations. R e fe rra l by h ea lth ca re p ro v id e rs to th e ex e rcise p ro g ram plays a critical role in the re c ru itm e n t p ro ce ss10,20; how ever, m an y o n co lo g ists re p o rt in su f ficient tim e to d iscu ss exercise p ro g ra m m in g w ith p atien ts21. E x istin g p artn e rsh ip s th at have helped the su stain ab ility o f b e a u t y include those w ith the Tom B ak er C an ce r C en tre, the B reast C an ce r S upportive C are F o u n d atio n , and W ellspring C algary.
2.7 Evaluation P ro g ra m su c c e ss is m e a s u re d as re c ru itm e n t into th e p ro g ra m , p a rtic ip a n t-re p o rte d satisfa c tio n w ith
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th e p ro g ra m , a n d m a in te n a n c e o r im p ro v e m e n ts in f a tig u e , h e a lt h - r e l a t e d q u a l i t y o f lif e , a n d p h y sic a l fitn e ss o u tc o m e s. In te rm s o f im m e d ia te im p a c t, all in fo rm a tio n c o lle c te d fo r p h y sic a l and p a tie n t-re p o rte d o u tc o m e s fe ed s d ire c tly b a c k to th e p a rtic ip a n ts , m o tiv a tin g th e m to m a in ta in a re g u la r p ro g ra m o f p h y sic a l a c tiv ity . T h e p a r tic i p a n ts in th e p ro g ra m have re c e n tly b e e n d ia g n o se d w ith b re a s t c a n c e r, a n d th e p ro g ra m h o p e s to f u l fil th e ir n e e d fo r in fo rm a tio n a n d to h e lp th e m re g a in so m e c o n tro l o v e r th e ir liv es d u rin g th e p o s t-d ia g n o s is p e r io d 16. T h e b e a u t y p ro g ra m is o n g o in g a n d th e re fo re is c o n tin u a lly b e in g re fin e d in r e g u la r q u a lity im p ro v em en t cycles. A n a ly se s are c u rre n tly u n d e r w ay to evaluate the program , and w ill utilize elem ents o f th e r e - a i m (R e a c h - E f f e c tiv e n e s s - A d o p tio n Im p le m e n ta tio n -M a in te n a n c e ) fra m e w o rk (h ttp :// w w w .re -a im .h n f e .v t.e d u /). T ab le n o u tlin e s th e p a ra m e te rs o f th e b e a u t y p ro g ra m th a t w e in te n d to e v a lu a te u sin g r e - a i m . L esso n s le a rn e d fro m the e v a lu a tio n o f b e a u t y w ill c o n trib u te to c o n tin u o u s q u a lity im p ro v e m e n t o f th e p ro g ra m a n d to th e g ro w th o f th e p ro g ra m in to a su sta in a b le c o m m u n ity re so u rc e .
Tiered exercise prescription for the beauty program
Exercise category
Red light (easiest)
Yellow light (moderate)
Green light (hardest)
Aerobic0
Heart rate should reach 40%-60% of age-predicted maximum, with a rated perceived exertion of 1-3, for 20-60 minutes
Heart rate should reach 40%-60% of age-predicted maximum, with a rated perceived exertion of 1-3, for 20-60 minutes
Heart rate should reach 40%-60% of age-predicted maximum, with a rated perceived exertion of 1-3, for 20-60 minutes
Resistance
1-2 sets, 8-12 repetitions, 5 exercises
1-3 sets, 8-12 repetitions, 7-8 exercises
2-3 sets, 8-12 repetitions, 10-14 exercises
Flexibility
5-7 days per week
5-7 days per week
5-7 days per week
Participants are instructed to adjust their heart rate, rating of perceived exertion, and exercise duration based on their perceived energy and fatigue on any given day (for example, a “green” day might mean reaching 60% of maximum heart rate for 60 minutes at a rated perceived exertion of 3, and a “red” day might mean exercising for 10 minutes at a time and reaching 40% of maximum heart rate at a rated perceived exertion of 1).
table
n Reach-Effectiveness-Adoption-Implementation-Maintenance (r e - aim ) evaluation of the beauty program Reach
Enrollment Annual enrollment compared with estimated number of breast cancer diagnoses in Calgary annually Representativeness Demographics of participants compared with demographics of women diagnosed with breast cancer in the Calgary area
Effectiveness
Adoption
Psychosocial Adherence and physiologic Attendance at centre exercise outcomes at sessions and self-reported 12 and 24 weeks compliance with home exercise Retention Completion of 12-week or 24-week assessment (or both)
Implementation
Maintenance
Safety of the Cost to run the program, defined program per as the number of participant adverse events Participant exercise reported behavior 6 months after program completion
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3. DISCUSSION AND CONCLUSIONS The beauty exercise program provides an ongoing and extrem ely im portant resource for w om en w ith breast cancer. A fter diagnosis, breast cancer patients and survivors need access to a supportive and safe exercise environm ent that is led by professionals w ith relevant cancer-specific training and that tar gets key concerns com m only seen in survivors (that is, fatigue, negative changes in body composition, physical functioning, and health-related quality of life). Given the im m ensely positive effect that exer cise can have not only on physical and psychosocial outcom es, but also on recurrence and survival rates, the im portance o f offering an evidence-based com m unity exercise program for this population cannot be underestim ated. T he beauty p ro g ra m a d d re sse s the gap b e tw e e n the level o f e v id e n c e for the benefits o f exercise a fte r a cancer diagnosis and tran slatio n to co m m u n ity p ro g ra m m in g 8. It is designed to oper ate in a “real-w orld” setting, em phasizing external validity and generalizability beyond the population o f an intervention or a random ized controlled trial. T his p rogram m odel, w hich is designed for b reast cancer patients who are currently undergoing treat m ent, has, like o ther com m u n ity -b ased physical a c tiv ity p ro g ra m s for c a n c e r su rv iv o rs 9" 13, the poten tial to in sp ire long-term behavioural change and to have a trem en d o u s positive im pact on the b reast c an cer com m unity.
4. ACKNOWLEDGMENTS The authors thank W ings o f Hope for their contribu tions to the beauty program
5. CONFLICT OF INTEREST DISCLOSURES The authors have no financial conflicts o f interest to declare.
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21. Peeters C, Stewart A, Segal R, Wouterloot E, Scott CG, Aubry T. Evaluation of a cancer exercise program: patient and physi cian beliefs. Psychooncology 2009;18:898-902.
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Correspondence to: S. Nicole C ulos-R eed, 2500 Uni versity Drive NW, Calgary, A lberta T2N 1N4. E -m ail: nculosre@ ucalgary.ca
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Faculty o f Kinesiology, U niversity o f Calgary, Calgary, AB. D ep artm en t o f Psychosocial R esources, Tom B aker C ancer Centre, Calgary, AB. D epartm ent o f Oncology, Faculty o f M edicine, U niversity o f Calgary, Calgary, AB.
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