Activity and advanced cancer: A grounded theory.

BACKGROUND: Cancer-related fatigue and loss of physical functioning are distressing symptoms which negatively impact the quality of life of people with advanced cancer. Physical activity has been shown to have positive effects on these symptoms in early-stage cancer, but previous research demonstrated an incongruence between people with advanced cancer's expressed interest and actual participation in a physical activity intervention. AIM: To gain an in-depth understanding of the experience of activity and quality of life in people with advanced cancer, using a classic grounded theory approach. DESIGN: Through the post-positivist lens of subtle realism, and informed by classic grounded theory methods, a two-phase, cross-sectional, qualitative study was conducted. For 7 days duration, participants wore an activPAL™ activity monitor and completed a daily record sheet, which were then used as qualitative probes for face-to-face, semi-structured interviews. SETTING/PARTICIPANTS: A total of 15 people with advanced cancer, aged 18 years or older, and with a median survival of 100 days from time of study consent, were recruited from an outpatient department of a tertiary cancer centre in Alberta, Canada. FINDINGS: Maintaining their responsibilities, no matter how small, was the prime motive for participants' behaviour. For people with advanced cancer, the minimum level of responsibility was dynamic and unique. It was achieved through a multifaceted interaction between the perceived benefits, prevailing conditions and mechanisms. CONCLUSION: This grounded theory enables understanding of activity as a mechanism through which responsibility is managed and may inform future behavioural interventions in people with advanced cancer.

Clinical characteristics of patients having single versus multiple patient encounters within a palliative care programme.

OBJECTIVE: The objective of this study was to describe the clinical characteristics of patient initial presentations, and to explore associations between patients' clinical characteristics at initial presentation and number of encounters (single vs multiple) to an integrated palliative care programme. METHODS: This was a retrospective study of a decedent cohort of 2922 patient initial presentations to the Edmonton Zone Palliative Care Program (EZPCP). Data included age, gender, setting of encounter, diagnosis, Edmonton Symptom Assessment System, CAGE, Mini-Mental Status Examination, Palliative Performance Status, Edmonton Classification System for Cancer Pain and time to death. RESULTS: On initial presentation to the EZPCP, the mean age was 73 (SD 14 years), with 1358 (46%) being female, and the majority having a cancer diagnosis (n=2376, 81%), the most common of which was gastrointestinal primary (n=681, 29%). In univariate analyses, patients with younger age (<60), higher palliative performance status (>40%), a malignant diagnosis, gastrointestinal primary or unimpaired cognition at initial presentation were significantly associated with multiple encounters with an integrated palliative care programme (p<0.05). In a multivariate regression analysis, a malignant diagnosis, longer survival, higher performance status and initial entry through acute care sites were independently associated with multiple encounters in the programme (p<0.001). CONCLUSIONS: Larger prospective studies are warranted to further elucidate the complex relationships between patient clinical characteristics, initial presentations and subsequent encounters to an integrated palliative care programme.

Physical activity in advanced cancer patients: a systematic review protocol.

BACKGROUND: Progressive, incurable cancer is associated with increased fatigue, increased muscle weakness, and reduced physical functioning, all of which negatively impact quality of life. Physical activity has demonstrated benefits on cancer-related fatigue and physical functioning in early-stage cancer patients; however, its impact on these outcomes in end-stage cancer has not been established. The aim of this systematic review is to determine the potential benefits, harms, and effects of physical activity interventions on quality of life outcomes in advanced cancer patients. METHODS/DESIGN: A systematic review of peer-reviewed literature on physical activity in advanced cancer patients will be undertaken. Empirical quantitative studies will be considered for inclusion if they present interventional or observational data on physical activity in advanced cancer patients. Searches will be conducted in the following electronic databases: CINAHL; CIRRIE Database of International Rehabilitation Research; Cochrane Database of Systematic Reviews (CDSR); Database of Abstracts of Reviews of Effects (DARE); Cochrane Central Register of Controlled Trials (CENTRAL); EMBASE; MEDLINE; PEDro: the Physiotherapy Evidence Database; PQDT; PsycInfo; PubMed; REHABDATA; Scopus; SPORTDiscus; and Web of Science, to identify relevant studies of interest. Additional strategies to identify relevant studies will include citation searches and evaluation of reference lists of included articles. Titles, abstracts, and keywords of identified studies from the search strategies will be screened for inclusion criteria. Two independent reviewers will conduct quality appraisal using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies (EPHPP) and the Cochrane risk of bias tool. A descriptive summary of included studies will describe the study designs, participant and activity characteristics, and objective and patient-reported outcomes. DISCUSSION: This systematic review will summarize the current evidence base on physical activity interventions in advanced cancer patients. The findings from this systematic review will identify gaps to be explored by future research studies and inform future practice guideline development of physical activity interventions in advanced cancer patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015026281.

Physical activity interests and preferences of cancer patients with brain metastases: a cross-sectional survey.

BACKGROUND: Physical activity has been shown to positively impact cancer-related fatigue, physical functioning and quality of life outcomes in early stage cancer patients, however its role at the end stage of cancer has yet to be determined. Brain metastases are amongst the most common neurological complications of advanced cancer, with significant deterioration in fatigue and quality of life. The purpose of the present study was to examine the physical activity interests and preferences of cancer patients with brain metastases initiating palliative whole brain radiotherapy. METHODS: Thirty-one patients aged 18 years or older, cognitively intact, diagnosed with brain metastases, and with Palliative Performance Scale scores of greater than 30%, were recruited from a multidisciplinary outpatient brain metastases clinic. An interviewer-administered survey was used to assess physical activity interests and preferences of participants who were embarking upon palliative whole brain radiotherapy. RESULTS: 87% (n = 27) of participants felt that physical activity was important, however there was limited interest in participating in a structured program at the onset of palliative whole brain radiotherapy. Lung cancer diagnosis was associated with being less interested in participating in a physical activity program, and feeling less able to participate in a physical activity program at the onset of palliative whole brain radiotherapy. CONCLUSIONS: Cancer patients with brain metastases demonstrate limited interest and varied preferences for physical activity during palliative whole brain radiotherapy. Additional pilot work with this patient population is needed before physical activity interventions can be tested in clinical research.

Correlates of objectively measured sedentary behavior in cancer patients with brain metastases: an application of the theory of planned behavior.

OBJECTIVE: The aim of this study is to examine the demographic, medical, and social-cognitive correlates of objectively measured sedentary behavior in advanced cancer patients with brain metastases. METHODS: Advanced cancer patients diagnosed with brain metastases, aged 18 years or older, cognitively intact, and with palliative performance scale greater than 30%, were recruited from a Rapid Access Palliative Radiotherapy Program multidisciplinary brain metastases clinic. A cross-sectional survey interview assessed the theory of planned behavior variables and medical and demographic information. Participants wore activPAL™ (PAL Technologies Ltd, Glasgow, United Kingdom) accelerometers recording time spent supine, sitting, standing, and stepping during 7 days encompassing palliative whole brain radiotherapy treatments. RESULTS: Thirty-one patients were recruited. Correlates of median time spent supine or sitting in hours per day were instrumental attitude (i.e., perceived benefits) of physical activity (r = -0.42; p = 0.030) and affective attitude (i.e., perceived enjoyment) of physical activity (r = -0.43; p = 0.024). Moreover, participants who sat or were supine for greater than 20.7 h per day reported significantly lower instrumental attitude (M = 0.7; 95% CI = 0.0-1.4; p = 0.051) and affective attitude (M = 0.7; 95% CI = 0.0-1.4; p = 0.041). Finally, participants who were older than 60 years of age spent more time sitting or being supine. CONCLUSIONS: Instrumental attitude and affective attitude were the strongest correlates of objectively measured sedentary behavior. This information could inform intervention studies to increase physical activity in advanced cancer patients with brain metastases.

Associations between objectively measured physical activity and quality of life in cancer patients with brain metastases.

CONTEXT: Physical activity has demonstrated benefits for quality of life (QoL) and cancer-related fatigue earlier in the cancer trajectory; however, less is known regarding its role in patients with end-stage cancer. OBJECTIVES: The primary aim of this study was to examine the association between objectively measured physical activity and QoL in cancer patients with brain metastases. METHODS: Patients diagnosed with brain metastases, aged 18 years or older, cognitively intact, and with Palliative Performance Scale scores greater than 30%, were recruited from a multidisciplinary brain metastases clinic. A cross-sectional survey interview assessed self-reported QoL (McGill Quality of Life Questionnaire), self-reported physical function (Late-Life Function and Disability Instrument), and symptoms (Edmonton Symptom Assessment System). Participants wore activPAL™ (PAL Technologies, Ltd., Glasgow, UK) accelerometers recording triaxial movement for seven days during palliative whole brain radiotherapy. RESULTS: A total of 31 patients were recruited. Median survival was 171 days from time of study consent, with 90% (28 of 31) of deaths by two year follow-up. Participants who stood for 1.6 hours or more per day had better QoL (mean=1.0; 95% confidence interval [CI]=0.1 to 1.9; P=0.034). Participants who stood for 1.6 hours or more per day had better QoL (mean=1.0; 95% CI=0.1 to 1.9; P=0.034). Participants who sat or were supine for 20.7 hours or more per day had better advanced lower extremity functioning (mean=-6.1; 95% CI=-11.9 to -0.3; P=0.040) and total functioning (mean=-10.6; 95% CI=-21.1 to -0.04; P=0.049), but worse depression (mean=2.1; 95% CI=0.3 to 3.9; P=0.028), anxiety (mean=2.8; 95% CI=0.7 to 5.0; P=0.012), and feeling of well-being (mean=1.9; 95% CI=0.2 to 3.6; P=0.028). CONCLUSION: Sedentary behavior appears to be associated with better physical functioning but worse psychosocial functioning in cancer patients with brain metastases.

Home-based functional walking program for advanced cancer patients receiving palliative care: a case series.

BACKGROUND: Although meta-analyses have demonstrated that physical activity can positively impact quality of life outcomes in early stage cancer patients, it is not yet known whether these benefits can be extended to patients with advanced cancer. In a previous pilot survey of patients with advanced cancer with a median survival of 104 days, participants felt willing and able to participate in a physical activity intervention, and reported a strong preference for walking and home-based programming. Here, we report on the initial development and feasibility of a home-based functional walking program in patients with advanced cancer receiving palliative care. METHODS: Nine adult patients were recruited from outpatient palliative care clinics and palliative home care. A pilot intervention trial was conducted over a 6-week period. The McGill Quality of Life Questionnaire (MQOL), Late Life Function and Disability Instrument (LLFDI), Edmonton Symptom Assessment System (ESAS), Seniors Fitness Test, four-test balance scale, and grip strength, were performed pre- and post-intervention. Participants wore activPAL™ accelerometers to monitor ambulatory activity levels. RESULTS: Of the nine recruited participants, three participants dropped out prior to baseline testing due to hospital admission and feeling overwhelmed, and three participants dropped out during the intervention due to severe symptoms. Only three participants completed the intervention program, pre- and post-intervention assessments: two reported improvements in total MQOL scores, yet all three shared an overall trend towards worsening symptom and total fatigue scores post-intervention. Two participants passed away within 90 days of completing the intervention. CONCLUSIONS: This case series demonstrates the challenges of a physical activity intervention in patients with advanced cancer receiving palliative care. Further feasibility research is required in this patient population. TRIAL REGISTRATION: This study is registered under ClinicalTrials.gov as NCT00438620.

Determinants of physical activity in palliative cancer patients: an application of the theory of planned behavior.

BACKGROUND: Increasing evidence points to the theory of planned behavior as a useful framework to understand physical activity behavior in cancer patients. OBJECTIVE: Our primary aim was to examine the demographic, medical, and social-cognitive correlates of physical activity in palliative cancer patients. METHODS: A cross-sectional survey was administered to advanced cancer patients aged 18 years or older with a clinician-estimated life expectancy of less than 12 months and Palliative Performance Scale >30%, from outpatient palliative care, oncology clinics, and palliative home care. RESULTS: Fifty participants were recruited. Correlates of total physical activity levels were affective attitude (r = 0.36, P = .011), self-efficacy (r = 0.36, P = .010), and intention (r = 0.30, P = .034). Participants who reported 60 minutes or more of total physical activity daily reported significantly higher affective attitude (M = 0.9, 95% confidence interval [CI] 0.26-1.6, P = .008) and self-efficacy (M = 0.8, 95% CI 0.0-1.5, P = .046). Participants <60 years of age (M = 343, 95% CI -7 to 693, P = .054) and who were normal or underweight (M = 333, 95% CI -14 to 680, P = .059) reported higher weekly minutes of total physical activity. LIMITATIONS: Our small sample may not be representative of the total palliative cancer population. CONCLUSIONS: Affective attitude, self-efficacy, and intention were the strongest correlates of total physical activity levels, and younger and normal/underweight participants did more physical activity.

Physical activity and palliative cancer care.

Palliative care is an interdisciplinary and holistic approach aimed at alleviating suffering from physical, psychosocial, and spiritual issues in progressive, advanced disease. Progressive fatigue and anorexia-cachexia syndrome can contribute to loss of physical function in the palliative cancer patient, to the detriment of overall quality of life. Physical activity is one potential intervention, which may address these needs in the palliative cancer patient. There is preliminary evidence that at least some palliative cancer patients are willing and able to tolerate physical activity interventions, with some patients demonstrating improvement in select supportive care outcomes postintervention. Methodologically rigorous studies and consensus on common definitions are required to advance this area of research.

Physical activity interests and preferences in palliative cancer patients.

GOALS OF THE WORK: The purpose of the present study was to examine the physical activity interests and preferences of palliative cancer patients. PATIENTS AND METHODS: Fifty advanced cancer patients aged 18 years or older with clinician-estimated life expectancy of less than 12 months and Palliative Performance Scale greater than 30% were recruited from an outpatient palliative care clinic and a palliative home care program. An interviewer-administered survey was used to assess physical activity behavior, interests, and preferences. MAIN RESULTS: The majority of palliative cancer patients in this sample indicated that they would be interested and felt able to participate in a physical activity program. There were strong preferences for home-based physical activity programs that could be completed alone. The majority of participants in this sample reported walking as the type of physical activity in which they were most interested. CONCLUSIONS: These findings suggest that this sample of palliative cancer patients is interested and feel able to participate in a physical activity program. Examining these unique physical activity preferences may aid in the development of an appropriate physical activity program for palliative cancer patients that can be tested in clinical research.

Associations between physical activity and quality of life in cancer patients receiving palliative care: a pilot survey.

The primary aim of this study was to examine the association between physical activity and quality of life (QoL) in cancer patients receiving palliative care. Fifty advanced cancer patients aged 18 years or older with clinician-estimated life expectancy of 3-12 months and Palliative Performance Status Scale scores greater than 30% were recruited from an outpatient palliative care clinic and palliative home care. Participants completed a cross-sectional survey by means of face-to-face interview assessing self-reported QoL (McGill Quality of Life Questionnaire [MQOL]), self-reported physical function (Late-Life Function and Disability Instrument), symptoms (Edmonton Symptom Assessment System), and physical activity behavior. Seventy-six percent (38 of 50) of the participants were deceased at the time of data analysis, with a median survival of 104 days from time of survey to time of death. Walking was the most common reported physical activity. Analyses of variance indicated that participants who reported walking more than 30 minutes per day also reported higher existential subscores (+/-0.8 [95% CI, 0.0-1.5]; P=0.045), support subscores (+/-0.7 [95% CI, 0.1-1.4]; P=0.027), and total scores (+/-0.5 [95% CI, 0.0-0.9]; P=0.046) on the MQOL. There were no significant differences for self-reported physical function or symptoms. Our findings show a significant positive association between physical activity and QoL scores in this sample of patients with advanced cancer. A pilot intervention trial testing the causal effects of physical activity on QoL in cancer patients receiving palliative care is warranted.

Physical activity as a supportive care intervention in palliative cancer patients: a systematic review.

Previous systematic reviews have concluded that physical activity improves supportive care outcomes in cancer patients, but the conclusions are based largely upon data from patients with early-stage cancer. The aim of this study was to systematically review the best available evidence of physical activity as a supportive care intervention in palliative cancer patients. All published studies examining the effect of physical activity interventions on quality of life, fatigue, and physical function outcomes in palliative cancer patients aged 18 years or older were included. Six studies were identified, with significant heterogeneity in terms of study design, participant characteristics, type of physical activity intervention, and outcomes. Although they generally reported positive preliminary findings, the overall methodologic quality of the studies was poor. There is insufficient evidence to evaluate the efficacy of physical activity as a supportive care intervention in palliative cancer patients; methodologically, rigorous studies with larger samples and appropriate comparison groups are warranted.

Is pain intensity a predictor of the complexity of cancer pain management?

PURPOSE: The lack of a standardized cancer pain (CP) classification system prompted the development of the Edmonton Classification System for Cancer Pain (ECS-CP). Its five features have demonstrated value in predicting pain management complexity. Pain intensity (PI) at initial assessment has been proposed as having additional predictive value. We hypothesized that patients with moderate to severe CP would take longer to achieve stable pain control, use higher opioid doses, and require more complicated analgesic regimens than would patients with mild CP at initial assessment. METHODS: A secondary analysis of a multicenter ECS-CP validation study involving patients with advanced cancer was conducted (n = 591). Associations between PI and length of time to stable pain control (Cox regression), final opioid dose (Kruskal-Wallis one-way analysis of variance), and number of adjuvant modalities (chi(2)) were calculated. PI at initial assessment was defined using a numerical scale as mild (0 to 3), moderate (4 to 6), or severe (7 to 10). RESULTS: Patients with moderate and severe pain required a significantly longer time to achieve stable pain control (P < .0001). PI was a significant predictor of length of time to stable pain control in the univariate regression analysis. The four significant predictors in the multivariate model were moderate and severe PI (P < .0001), age (P = .001), and neuropathic pain (P = .002). Patients with moderate to severe pain required significantly higher final opioid doses (P < .0001) and more adjuvant modalities (P = .015). CONCLUSION: PI at initial assessment is a significant predictor of pain management complexity and length of time to stable pain control. Incorporation of this feature into the ECS-CP needs additional consideration.

Should the rate of opioid dose escalation be included as a feature in a cancer pain classification system?

The purpose of this study was to assess the need for opioid dose escalation as a feature of a pain classification system for advanced cancer patients. Opioid dose escalation was included as a prognostic feature in the original Edmonton Staging System (ESS) for pain classification, but was not included among the five features of the revised ESS (rESS): pain mechanism, incident pain, psychological distress, addictive behavior, and cognitive function. Mercadante et al.'s definition of opioid escalation index percentage (OEI%) has been used as a surrogate marker for opioid responsiveness. Our hypothesis was that younger age (<60 years), neuropathic pain, incident pain, psychological distress, and addictive behavior would be associated with an OEI% >5%. Using data from a recent multicenter validation study of the rESS, a secondary analysis of a subsample of 532 advanced cancer patients with a pain syndrome was conducted. Approximately 44% (n=232) of the patients had an OEI% >5%. There were no significant associations between OEI% and age, neuropathic pain, incident pain, psychological distress, or addictive behavior. As originally proposed as a clinical marker, the OEI% may oversimplify the complexity of pain management in advanced cancer patients. Future studies are required to better elucidate the need for opioid dose escalation as a feature of a cancer pain classification system.