Exercise is medicine in cancer! But how do we implement exercise into routine clinical care?
Bibliographic record
Abstract
“Exercise is medicine in cancer!” is a statement that is based on a large body of scientific evidence and continues to be increasingly incorporated into the care of oncological patients. Exercise has become an important pillar in the prevention and treatment of cancer- and cancer-treatment-related side effects. Despite the extensive evidence on the effects of exercise in cancer, the implementation of cancer exercise programs is still heterogenous and fragmentary. Barriers to offer cancer-specific exercise opportunities are diverse and are mostly located on the level of finances, education, personnel resources and missing collaborations. Moreover, the majority of health care professionals (HPCs) do not recommend exercise as a standard of their oncological care plan nor do they refer patients into local exercise programs. Further, due to the complexity of cancer disease and the diverse side effects of its treatment, different types of exercise offerings are required, ranging from general community-based programs to very specific and individually supervised offerings. Due to the presented issues, different exercise care pathway models have been developed in the US, Canada and Australia in which the treating HCP advises physical activity to their patients and refers them into suitable exercise programs. As a leading example in Germany, the network OnkoAktiv provides a professional network of clinical institutions including their HCPs and quality-assessed cancer exercise programs to enable comprehensive exercise care. Although OnkoAktiv has been seen as a successful running example of an exercise care network, the network has not been evaluated to date. Moreover, there is a gap of knowledge about how to implement exercise into different settings of the German health care system. Given this urgent need for research, this cumulative dissertation intended to contribute to the following research areas by (a) investigating exercise implementation barriers and facilitators of the network OnkoAktiv institutions, (b) analysing and illustrating the network compositions of the regional OnkoAktiv networks and to define practical implications for further network development and (c) giving an overview about existing oncological exercise programs in the European region and to discuss current cancer exercise implementation perspectives in Europe. The three manuscripts contained in this dissertation present results of three different studies. All studies are part of the comprehensive evaluation concept of the networks OnkoAktiv and aimed to evaluate OnkoAktiv on two levels, the regional OnkoAktiv networks (RE) and certified training institutions (TR) as well as the network frame (European exercise programs). The evaluation of the regional OnkoAktiv networks (RE) and certified training institutions (TR) in the first manuscript was executed in a sequential mixed methods design. 16 qualitative interviews were conducted with the leaders of the RE and TR. Then, 89 TR were invited to a quantitative, cross-sectional survey. 11 facilitators each for RE and TR, 7 barriers for RE and 5 for TR could be found. Barriers were for example missing comprehensive funding concepts for the OnkoAktiv network structures, a lack of knowledge of HCPs and exercise trainers, low numbers of patient referral, and missing collaborations between network stakeholders. Facilitators could be identified on the level of internal organizational resources, support by OnkoAktiv staff and collaboration between exercise institutions and HCPs. The findings indicate challenges on different level of OnkoAktiv for the implementation of exercise network structures. The second manuscript aimed to analyse the structure of the individual regional OnkoAktiv networks and classified them into their organisational forms. A social network analysis could be performed for 11 regional OnkoAktiv networks. In smaller networks, several individual professionals were linked “from service to service” through linkage, whereas the more integrated networks revealed a core-periphery-structure. Overall, collaborative networks such as OnkoAktiv enable the involvement of professional actors from different operational fields. Linking different actors and building a network core for control and organization is important for building networks such as OnkoAktiv. The third manuscript intended to analyse existing cancer-specific exercise programs in the European Union and neighbouring countries and to discuss implementation perspectives in the European context. Through a cross-sectional survey, 81 exercise programs from 15 different countries could be investigated. The included exercise programs were highly diverse in terms of structural and organizational characteristics and there was a high need of collaborations with HCPs and educational courses for trainers. For the integration of exercise into existing cancer care settings, a close interaction and collaboration between the cancer clinicians and exercise providers is necessary. All in all, this cumulative dissertation provides a roadmap on why, where and how to implement exercise into cancer care structures in Germany, including barriers, facilitators, important stakeholder and organisational steps that should be considered.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.030 | 0.089 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.002 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.004 | 0.006 |
| Scholarly communication | 0.009 | 0.015 |
| Open science | 0.003 | 0.008 |
| Research integrity | 0.008 | 0.017 |
| Insufficient payload (model declined to judge) | 0.015 | 0.007 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".