BACKGROUND & RATIONALE. Exercise, or physical activity, is beneficial for all cancer survivors. Despite this
knowledge, there is generally a gap between the evidence and practice. And this gap is
widened with (a) underserved tumour groups in exercise oncology, such as neuro-oncology
patients, or (b) underutilized timelines across the cancer treatment phases to deliver
exercise oncology education or programming.
Within Alberta (AB), the investigators have been able to very successfully implement the
Alberta Cancer Exercise (ACE) program to start to address the gap between research and
practice. As a hybrid implementation effectiveness study, ACE is building a model for
exercise oncology delivery within standard cancer care. With over 2500 participants across
AB, the investigators have substantial evidence supporting the feasibility of ACE, as well as
the potential benefits. Despite these successes, ACE remains primarily represented by
participants from breast, prostate, and colorectal tumour groups. This represents a lack of
connection between smaller and more high risk tumour groups within referral pathways for the
ACE program, both at TBCC and CCI, but also within the regional community cancer clinics
(Grande Prairie, Red Deer, Medicine Hat, Lethbridge).
RESEARCH QUESTION & OBJECTIVES. The purpose of this feasibility-implementation study is to build exercise into the clinical
care pathway in neuro-oncology clinics at the two major cancer centres in AB, where all
neuro-oncology patients provincially are treated (Tom Baker Cancer Centre, TBCC; and the
Cross Cancer Institute, CCI). Specifically, the objectives of the proposed work are:
- (1) to
tailor the ACE exercise program for all neuro- oncology patients, to ACE-Neuro; this includes
considering additional tailoring to address needs earlier in the care pathway, from diagnosis
through treatment (i.e., prehabilitation phases) and into longer term survivorship (wellness
cancer survivorship care plans), (2) to provide models of delivery of exercise oncology
programs to enhance access (i.e., remote delivery, home support, individual vs.#46;group), and
(3) to build this systematically within the neuro-oncology clinics at the TBCC and CCI, to
ensure that all patients diagnosed with brain tumours can access wellness during their cancer
care journey.
The investigators hypothesize that there will be improvements in patients'
physical and psychosocial well-being (individual level outcomes), as well as a more
integrated workflow in the clinical cancer care setting that includes exercise as part of
standard clinical practice (systems level outcome). Specifically, the primary outcome of this
study is to determine the feasibility of recruitment, referral, triage, adherence, and
adverse events. The secondary outcome is to examine the preliminary effectiveness of the
neuro-oncology exercise program on patient-reported outcomes and physical function.
METHODS. Using the successful implementation model developed in ACE, the proposed work will build a
neuro-oncology cohort within a mixed methods study design. There will be multiple phases to
the implementation of ACE-Neuro, including:
1. Building awareness within the clinical teams, identifying site champions, and providing
educational and referral resources specific to neuro-oncology and exercise;
2. Working with neuro-oncology patients and families to develop the unique aspects of
exercise programming (from "move more" programs to "exercise") to address identified
needs. This co-creation process will also include the cancer physiatry team (Dr. George
Francis, Dr. Lauren Capozzi) and the clinical neuro-oncology teams (Dr. Gloria Roldan
Urgoiti at TBCC and Dr. Jay Easaw at CCI) to address medical clinical needs that can be
addressed within the ACE-Neuro program, and clinical workflow logistics with physiatry
and physiotherapy to address specific treatment-related side effects (such as limb
weakness, balance, or cognitive function);
3. implementation of the ACE-Neuro tailored program, including referral, screening,
assessments, intervention delivery, and follow-ups. Details of the ACE-Neuro procedures
are detailed below.
REFERRAL AND RECRUITMENT. Because the main outcome of this study is feasibility, and the ultimate goal is to build
ACE-Neuro into standard neuro-oncology care, no a priori sample size has been calculated.
Based on current clinical numbers, and previous work done with neuro-oncology patients at
CCI, the investigators anticipate approximately 25-30 eligible patients per year, per site.
Our aim is to referral of all eligible neuro-oncology patients from TBCC. For recruitment,
patients can:
1. self-refer (i.e. patient contacts the study team from a poster or brochure received in
clinic, through word of mouth);
OR study team can refer:
2. clinical team sends referral to rehab oncology via Putting Patients First Questionnaire
(via ARIA).
The clinical team, based on their judgment, may not refer patients they deem to be
ineligible. This may include for the following reasons:
1. Patient is not interested when exercise idea is brought up.
2. Health care provider deems patient clinically ineligible, due to disease progression,
end-of-life care, or other health factor. 3. Patient does not speak English. 4. Other. As a feasibility study, reasons for non-referral will be tracked, with no identifying patient
information, across the recruitment period. After consenting to the study, all patients will
undergo a two-part screening procedure prior to beginning the exercise program:
1. Patients will complete health and medical history screening using the Health History
Questionnaire, Identifying Information Questionnaire, and the Physical Activity
Readiness Questionnaire; PAR-Q.
2. Patients will attend a Neuro Oncology Rehabilitation Triage Clinic, led by a Resident
Physician (Dr. Lauren Capozzi; supervised by Dr. George Francis) and the ACE-Neuro Study
Coordinator (Julia Daun). During this 30-minute appointment, patients will complete the
Short Physical Performance Battery screening test6, and a full neurological exam,
including Karnofsky performance and Eastern Cooperative Oncology Group (ECOG) scores.
This appointment will assess the patients' readiness for participating in ACE-Neuro.
As part of this study, the investigators will be tracking the referral pathway, and which
method of referral is most feasible as part of standard clinical workflow.
ASSESSMENTS. 1. Patient-Reported Outcomes (PROs)
- - will include symptom burden (Edmonton Symptom
Assessment Scale-Revised; ESAS-r), PA levels (Godin Leisure Time Exercise
Questionnaire-Modified; GLTEQ), quality of life (Functional Assessment of Cancer
Therapy-Brain; FACT-Br), cognitive function (Functional Assessment of Cancer
Therapy-Cognitive Scale; FACT-Cog), and fatigue (Functional Assessment of Chronic
Illness Therapy-Fatigue; FACIT-F).
2. Functional Fitness Assessments
- - will follow the set protocols within ACE (HREBA-CC-16-
0905_MOD12), and are designed to be able to be completed in-person or via remote
delivery (online assessment).
All fitness assessments will be completed by a Clinical
Exercise Physiologist and will include the assessment of lower body strength and
endurance (30-second sit-to-stand), static balance (single leg stance), flexibility
(sit-and-reach and active shoulder flexion), and cardiorespiratory fitness (2-minute
step test or 6MWT).
3. Objective Physical Activity
- - will be measured via the use of a wrist-worn activity
tracker (WAT; i.e., Garmin vivosmart® 4).
Garmin wearable PA trackers are widely used
across health research, and will be provided to all participants to objectively track PA
habits throughout the intervention.
4. Qualitative Interviews and Photo Elicitation: Qualitative data will be gathered across
the co-creation process via interviews and photo elicitation, to inform the feasibility
of ACE-Neuro, as well as to assess outcomes associated with participation in the
ACE-Neuro program (benefits, barriers, satisfaction, impact on well-being). Qualitative
data will be stored on a secure server.
HEALTH COACHING. In addition to exercise delivery and assessments, all participants will have the choice to
participate in evidence-based health coaching calls, provided by a trained Health Coach.
Health coaching is an evidence-based tool that supports positive health behaviour change
across cancer populations. Health coaching calls will take place weekly for 15-30 minutes
following an individualized exercise training session, and include topics surrounding goal
setting, social support, stress management, maintaining motivation, and overcoming barriers.
Health coaching calls will be delivered remotely (e.g., via end-to-end encrypted Zoom or
phone call) at the participants' preferred date and time.
TIMELINE. The described exercise program and data collection of PROs and functional fitness assessments
are in addition to standard practices. The timeline for these assessments include: baseline
(at recruitment into ACE-Neuro), 12-weeks (post-intervention), 6-months, and 12-months.
ANALYSIS Quantitative analysis will include descriptive statistics (means, medians, standard
deviations), and change scores to measure changes in outcomes over time. Qualitative data
will be analyzed by verbatim transcription (in NVivo), using an interpretive description
methodology. Both quantitative and qualitative data will be analyzed to provide a deeper
understanding of the feasibility and impact of ACE-Neuro.
RELEVANCE By working directly with patients, healthcare providers, and community partners,
this implementation project will develop a framework that streamlines patient triage, and
provides a tailored online exercise program for neuro-oncology patients, thereby advancing
exercise oncology research and clinical practice.
