Incorporating Strength Training into Cancer Care: Translating PAL into the Strength After Breast Cancer Program.

Abstract

Multiple national organizations recommend exercise for those affected by cancer (1-3). These recommendations, from the American College of Sports Medicine (1), American Cancer Society (2), and the National Comprehensive Cancer Network (3), all include guidance to participate in strength training two to three times weekly. In one survey of cancer survivors, 19% of respondents indicated they adhered to the strength training guidance from these published recommendations from expert panels (4). This is despite documented benefits of regular strength training among cancer survivors. Our research team has contributed to the evidence base documenting the safety and efficacy of strength training among breast cancer survivors in a series of studies that included women with and at risk for breast-cancer-related lymphedema (5-7). Documented benefits of strength training among breast cancer survivors include improved strength and body composition, physical function, quality of life, and body image, as well as reductions in anxiety and depression (8-13). Based on these benefits and recommendations, there is value to efforts to connect breast cancer survivors to high-quality strength training programs. We set out to address this in the novel setting of outpatient rehabilitation, followed by home training, in an NCI-funded R21 entitled “Disseminating the Physical Activity and Lymphedema Trial (PAL).” In the original research, the intervention had been delivered by fitness staff at eight YMCA branches. Concerns regarding staff turnover, YMCA culture to allow staff not trained to deliver the intervention (observed in multiple settings), safety, and pre-evaluation quality resulted in a choice to revise the intervention setting to outpatient rehabilitation. The details of Disseminating PAL are published elsewhere (14). In summary, we developed trainings for oncology clinicians to make referrals into the program, as well as trainings for outpatient rehabilitation clinicians to deliver the intervention. We changed the name of the program, based on patient feedback, to Strength After Breast Cancer. The safety and effectiveness demonstrated in the original randomized controlled trial was maintained. We learned that group physical therapy sessions were a challenge in clinics for which there was no billing code for group sessions. We also learned that insurance coverage for outpatient rehabilitation required careful review of the billing codes used and that copay amounts varied dramatically. Oncology clinicians had a difficult time making referrals due to limited face time with patients. Oncology nursing staff were vital to completing the referral steps. In addition, less than 30% of women referred to the program actually called to make an appointment to start the program until a champion in the outpatient rehabilitation clinic took on making follow-up phone calls. Once this active follow-up protocol was enacted, close to 70% of women referred initiated the program. This physical therapist champion was vital to the success of the program. Post study, we have partnered with Klose Training to develop a 4-hour online training to address three common challenges to connecting patients to high-quality strength training programming: location, triage, and training (http://klosetraining.com/course/online/strength-abc). Over 450 people have completed the training at this writing. In addition, Select Medical, Inc. is currently piloting efforts to roll out the program across 1,600 outpatient rehabilitation clinics. This should help with challenges of location, triage, and training. The challenge of cost continues to be an issue, even with most insurance carriers covering the program. Copays remain an issue, and finding ways for patients to afford home equipment (e.g., dumbbells) is also a challenge. In conclusion, triage, training, cost, and location are among the challenges to be addressed so that more cancer survivors are provided the support needed to benefit from exercise during and after treatment. Our ongoing trial, called ENACT (Exercise in All Chemotherapy, ClinicalTrials.gov study 00005664), is enrolling 250 cancer patients during infusion therapy and providing evaluation (triage) and counseling from an expert cancer exercise trainer using the Sunflower Wellness approach (sunflowerwellness.org), which includes five elements: balance, strength, endurance, flexibility, and mindful rest. We have enrolled 41 patients in 3 months. Eighty-five percent of those approached opt to consent. The intervention takes place in the exercise medicine unit at the Penn State Cancer Institute, which is housed within the chemotherapy infusion suite. While our early results support the behavioral feasibility of this approach for the patients and clinicians, the safety, efficacy, and disseminability to other locations remain to be demonstrated. Our team has taken an approach to ensuring safety, appropriate evaluations, and efficacy that is decidedly more clinically focused than some others in the field of exercise oncology. In my opinion, this approach is understudied compared to the completely community- and home-based approaches. There remains value to clinic-based evaluations and exercise programming for a subset of those affected by cancer. One commonly held goal across clinical and community-based research is providing appropriate bridges and referrals to make it easy for patients to access high-quality exercise programming.