Histologically diagnosed breast cancer <6–10 weeks before recruitment; stage M0; scheduled for chemotherapy; aged 25–75 years (PACT)/aged >18 years (PACES); Karnofsky performance status ≥60; no contraindications for physical activity; no cardiovascular, serious orthopedic, or cardiopulmonary conditions; no malnutrition; basic fluency in Dutch language; no psychiatric or cognitive problems
Histologically diagnosed breast cancer; completed (neo)adjuvant chemotherapy; no contraindications for exercise; able to perform basic activities; no psychiatric or cognitive problems; basic fluency of Dutch language
Participation rate
44% and 48%
47% and 52%b
Barriers to participation
Time/mental burden (34–40%); travel distance to hospital (12–22%); problem with random assignment (11–15%); want to exercise by him-/herself (24%); poor timing (22%); does not want to exercise (18%); unknown (1–23%)
Mental burden (26–55%); not interested/did not want to exercise (8–19%); already exercising (17–23%); problem with randomization (10%); unknown (8–21%)
Characteristic participants versus nonparticipantsc
Higher educational level, more likely to be employed, less fatigue, higher HRQoL, higher self-efficacy, fewer negative attitudes, more social support, more benefits and fewer barriers, lower self-reported activity level; lower cancer stage (I-II); less likely to have had a mastectomy
Patient satisfaction with supervised exercise programl
Average scores:
Average score:
8.5 out of 10 on overall satisfaction with the exercise program
8.4 out of 10 on overall satisfaction with the exercise program
9.4 out of 10 on “would you recommend this program to fellow patients?”
Experiences (positive): (i) Benefits (better physical fitness, positive feelings, more energy, fulfilment, better appetite and confidence in and positivity about the body) (44%) (ii) Good timing of the exercise intervention (63–91%) (iii) Intensity and load of the program overall (90%)
Experiences (positive): (i) Improvement in physical fitness (LMI: 20%, MHI: 28%, and HI: 26%) (ii) Guidance by the physical therapist with regard to the supervised exercises (LMI: 21%, MHI: 23%, and HI: 21%) (iii) Exercising with peers (LMI: 12%, MHI: 3%, and HI: 9%)
Experiences (negative or suggestions): (i) Intervention was burdensome (burdensome directly after chemotherapy or when ill) (4–25%) (ii) Inadequate supervision (e.g., no discussion of the diary and lack of continuity of supervision) (20%) (iii) Difficulty with scheduling (16–18%) (iv) More variation in training (by adding, for example, yoga or aerobics and more personalized supervision) (45%) (v) Total duration of intervention period too short (32%)
Experiences (negative or suggestions): (i) Training (too) heavy or (too) exhausting (LMI: 2%, MHI: 12%, and HI: 17%) (ii) Difficulty with scheduling (LMI: 8%, MHI: 10%, HI: 10%) (iii) The program as not being tailored enough (LMI: 6%, MHI: 16%, and HI: 10%) (iv) Improved variation in exercises and/or less arm exercises (LMI: 7%, MHI: 26%, and HI: 5%)
Patient satisfaction with unsupervised exercise programl
Average scores:
NA
7.4 out of 10 on overall satisfaction
8.2 out of 10 on “would you recommend this program to fellow patients?”
Experiences (positive): (i) Structure on how to be physically active (38%) (ii) Benefits (physical fitness gave less stress and fatigue and made them feel better and happier) (29%)
Experiences (negative): (i) Limited counseling (42%) (ii) The diary is burdensome (19%)
Adoption
Guidance of the exercise programs
(i) Patients in the Dutch RCTs were referred to a trained PT close to their home to guide the exercise intervention. The PTs were trained on the specific exercise protocols by the coordinating researcher before the start of the intervention (ii) In the Netherlands, PTs are the exercise professionals whom are dedicated to supervise the exercise programs for patients during chemotherapy
Satisfaction of physical therapistsl
(i) 20 PTs rated the exercise intervention after chemotherapy with a 7.5 out of 10 (ii) Preference for HI over LMI, but with the suggestion to start with LMI in patients with reduced physical fitness (iii) Preference for a more flexible exercise protocol to be able to improve variation of exercises (iv) Counseling techniques were rated with a 7 out of 10, with remarks that the counseling was not always possible in the available time (20%) and PTs expressed a need for education with regard to counseling techniques (10%)l
Higher educational level, low BMI, higher disease stage, having a partner
NA
LMI
HI
Unsupervised
Higher baseline endurance time, attitude
Treatment with hormonal therapy
Sport history, higher exercise stage, radiotherapy, higher self-efficacy, positive attitude, less barriers
Exercise advice
Higher baseline fitness (endurance time)
Predictors of high compliancea,o,p
Aerobic
Duration
Intensity
NA
LMI
HI
No significant predictors
Low levels of baseline physical fatigue; no addition of radiotherapy to chemotherapy
No employment at baseline
Higher self-efficacy and positive attitude
Resistance
Her2+ and ER or PR + tumor type (vs. triple negative); lower BMI; lower baseline PA
NA
LMI
HI
No employment at baseline and lower education
Having a more positive attitude towards exercise
Exercise advice
Beliefs about PA; higher baseline PA; peak O2 consumption
Implementation–cost-effectiveness
Currently, physical therapy is not reimbursed through basic healthcare insurance in the Netherlands. For patients who have been hospitalized prior to their chemotherapy or had radiotherapy sessions in the past 6 months, physical therapy is covered starting from the 21st session. Hence, patients who receive neoadjuvant chemotherapy are not entitled to any reimbursement from basic coverage, and patients who receive adjuvant chemotherapy face out-of-pocket expenses for the first 20 sessions, unless they have additional coverage packages
(i) The OnTrack intervention (PACES trial) was found to be cost-effective for QALYs Mean intervention costs for the supervised intervention were 756.67 euros per participant. The probability of OnTrack being cost-effective compared with UC was 45% at a willingness-to-pay of 20.000€/QALY and 79% at a willingness-to-pay of €80.000/QALY (ii) The probability that the PACT intervention is cost-effective for patients with breast cancer is 2% for a willingness-to-pay 20.000/QALY and 6% for a willingness-to-pay €80.000/QALY
(i) The probability that HI was cost-effective compared to LMI exercise was 0.91 at 20.000€/QALY and 0.95 at 52.000€/QALY
Unsupervised
(i) The unsupervised OncoMove intervention (PACES trial) was found not to be cost-effective (ii) Mean intervention costs for the unsupervised intervention were 46 euros per participant. The probability of cost-effectiveness was 25% at a willingness-to-pay of 20.000€/QALY and 55% at a willingness-to-pay of €80.000/QALY
(i) Existence of a broad network of PTs trained to guide patients with cancer with exercise during and after chemotherapy (ii) All PTs within the network follow mandatory refresher courses and have to pass summative tests related to these courses (iii) The network covers most of the populated areas in the Netherlands, and an specialized PT is available within a 15 min commute for most people
Oncology specializations for physical therapists
2 types of specializations: (1) Around 127 physical therapists have a master degree in oncology physical therapy, a three-year (60–96ECs) part-time study which covers both hands-on treatment of oncology patients and guidance of patients in exercise programs (2) Over 550 PTs working at over 700 locations in the Netherlands have been specifically educated on exercise treatment during and after treatment, via the Onconet courses executed by the Dutch Institute of Allied Healthcare. These PTs have received 67 hours or more of additional training in subjects such as basic oncology, exercise oncology, behavioral support, dealing with cancer-specific side effects, dealing with comorbidities, using clinimetrics, and clinical reasoning in an oncology context
Indicate effects in favor of the control group. EC: European credits; HI: high intensity; IQR: interquartile range; LMI: low-to-moderate intensity; MHI: moderate-to-high intensity; PT: physical therapist; QALY: quality-adjusted life year; WLC: wait list control. aUnpublished results of the REACT trial (additional analysis on data from patients with breast cancer only); analysis on predictors for participation with multivariable logistic regression; analysis on predictors for adherence performed with univariate logistic regression; brelatively high participation rate of 52% due to the trials within cohorts (TwiCs) design; ca comparison of characteristics between participants and a subgroup of nonparticipants (patients who did not want to exercise) [26]; da comparison of characteristics between participants and a subgroup of nonparticipants (who want to exercise by themselves); ecombined characteristics of 2 separate studies as reported in Gal et al., 2021 [32] combined with unpublished results REACTa; fin case, effect sizes of 2 studies were available for the same outcome, and this is reported for instance as 0.23 and 0.29; gevaluated using cardiopulmonary exercise testing (peak power output, watt) [18, 27] and steep ramp test (maximal short exercise capacity, watt) [24]; hevaluated using a cybex dynamometer at angular velocities of 60°/s; ievaluated with a handheld dynamometer; junpublished results of the PACT trial; kunpublished results of the UMBRELLA Fit trial; lthe percentages presented are calculated by the number of specific suggestions divided by the total number of suggestions; mthe percentages are calculated by the number of specific suggestions divided by the number of PTs that rated their satisfaction (n = 20); nattendance: number of supervised exercise sessions attended/number of supervised sessions offered; ocompliance: achieved intensity and volume/prescribed intensity and volume of both resistance and endurance exercises; ppredictors are reported if ;qperforming the total prescribed number of minutes; rperforming the prescribed number of minutes at or above the VT.
