Rehabilitation in cancer survivors - with focus on physical activity
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AbstractThe number of cancer survivors in the Western world has markedly increased over the last few decades. With the growing number of survivors, it has become relevant to address the health of cancer survivors and how to improve it. The malignancy, and more often the cancer treatment, might have negative effects upon physical and psychological aspects of the survivors’ health. For those who experience such adverse effects, professional assistance in addition to their own efforts might be needed in order to reach their optimal functional level. The overriding aim of this thesis was to investigate different aspects of rehabilitation in cancer survivors, with a focus on physical activity. This was examined in three different studies (data sets) and published in four separate papers.
In Paper I (Study A) we examined cancer patients’ needs for rehabilitation services and factors associated with such needs. In addition we identified unmet needs for rehabilitation services and factors associated with such unmet needs. More than 1300 cancer patients with the ten most prevalent cancers received a questionnaire two-three years after diagnosis. Approximately two thirds of the participants reported a need for at least one rehabilitation service. Need for physical therapy was most reported, followed by physical training and psychological counselling. Changes in employment status due to cancer and having received chemotherapy were associated with reporting needs for all rehabilitation services. Forty percent reported unmet needs, which most frequently were reported among persons living alone, who had changed their employment status due to cancer, had received chemotherapy or reported comorbidities.
In Paper II (Study B) we investigated the interest and preferences for exercise counselling and exercise programming among Norwegian cancer survivors and identified associated demographic and medical factors. More than 1200 cancer patients within five years after treatment, with six different diagnoses, completed a questionnaire. Overall, approximately 75% of the participants were somewhat interested in receiving exercise counselling at some point during their cancer trajectory. In men, the interest in exercise counselling was associated with younger age, presence of comorbidities, and having received chemotherapy. In women, the interest was associated with younger age, higher education and reduced physical activity level. The participants preferred face-to-face exercise counselling with an exercise specialist from a cancer center. Nine out of ten cancer survivors were somewhat interested in an exercise program, with walking as the preferred activity, at moderate intensity, and they wanted to start exercise immediately after end of treatment.
In Paper III (Study B) we estimated the proportion of cancer survivors who were physically active after treatment and examined changes in activity level from before diagnosis to after end of treatment. We also identified medical and demographic factors associated with activity level and change in activity level. Almost 1000 patients, within five years after treatment, with six different diagnoses, completed the Godin Leisure-Time Exercise Questionnaire (GLTEQ). Exercise was reported before diagnosis (retrospectively) and after end of treatment (at time of survey). Less than half of the survivors were physically active after treatment. One third was active both before diagnosis and after treatment, whereas 40% were inactive at both time points. Fifteen percent were active before diagnosis but inactive after treatment, and 12% were inactive before diagnosis but active after treatment. Increasing age and weight, low education level, presence of comorbidity and smoking were associated with physical inactivity after treatment. Change in activity level from active to inactive was associated with presence of comorbidities, distant disease and smoking, while changing from being inactive to active was associated with a high education level.
In Paper IV (Study C) we explored the effects of a 1-week inpatient course including information, physical activity (PA) and group sessions on physical and mental health-related outcomes in prostate cancer (PCa) patients. The PCa patients (N = 51) completed a questionnaire assessing PA (GLTEQ), fatigue (Fatigue Questionnaire), mental distress (Memorial Anxiety Scale for PCa and Hospital Anxiety and Depression Scale) and quality of life (QoL) (Global QoL from The European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire C30) one month before (T0) and three months after (T1) the course. Total fatigue, physical fatigue and PSA-anxiety decreased significantly from T0 to T1. No significant changes were observed for the other outcomes. In spite of minor reductions in levels of fatigue and PSA-anxiety, the findings indicate that a 1-week inpatient course does not influence substantially on the health-related outcomes in PCa patients three months after the course.
In conclusion, the majority of cancer survivors reported need and interest for rehabilitation services, especially physical support as physiotherapy and exercise counselling. Several demographic and medical factors were associated with need for different rehabilitation services. Such knowledge can contribute to offer suitable rehabilitation services to specific groups of cancer survivors. In addition a significant amount reported an unmet need. Less than half of cancer survivors were physically active after treatment. In order to increase or maintain the level of PA in cancer patients, special efforts should be directed towards identified cancer survivors in risk of physically inactivity after treatment. Minor effects were observed from a 1-week inpatient course. More research is needed directed towards more homogenous group of patients with anticipated recovery capacity for documentation of effects of ongoing types of courses. The length of the interventions should also be further investigated.
List of papers. Papers I and II are removed from the thesis due to copyright restrictions.
Paper I Thorsen L., Gjerset G.M., Kiserud C.E., Fosså S.D., Skovlund E., Fløtten T. and Loge J.H.: Cancer patients’ need for rehabilitation services. Acta Oncologica, 2011; 50 (2): 212-222. doi:10.3109/0284186X.2010.531050
Paper II Gjerset G.M., Fosså S.D., Courneya K., Jacobsen A.B., Skovlund E. and Thorsen L.: Interest and preferences for exercise counselling and programming among Norwegian cancer survivors. European Journal of Cancer Care, 2011; 20 (1): 96–105. doi:10.1111/j.1365-2354.2009.01161.x
Paper III Gjerset G.M., Fosså S.D., Courneya K., Skovlund E. and Thorsen L.: Exercise behavior in cancer survivors and associated factors. Journal of Cancer Survivorship, 2011; 5 (1): 35-43. Published with open access at Springerlink.com doi:10.1007/s11764-010-0148-4
Paper IV Gjerset G.M., Fosså S.D., Dahl A.A., Loge J.H., Ensby T. and Thorsen L.: Effects of a 1-week inpatient course including information, physical activity, and group sessions for prostate cancer patients. Journal of Cancer Education, 2011, 26 (4): 754-760. Published with open access at Springerlink.com doi:10.1007/s13187-011-0245-8