Implementing supportive exercise interventions in the colorectal cancer care pathway: a process evaluation of the PREPARE-ABC randomised controlled trial.

Abstract

Background: A colorectal resection is standard treatment for patients with colorectal cancer (CRC). However, the procedure results in significant post-operative mortality and reduced quality of life. Maximising pre-operative cardiopulmonary fitness could improve post-surgical outcomes. PREPARE-ABC is a multi-centre, three-armed, randomised controlled trial investigating the effects of exercise interventions, with motivational support on short and longer-term recovery outcomes in CRC patients undergoing major lower-gastrointestinal surgery. The trial included an internal pilot phase with parallel process evaluation. The aim of the process evaluation was to optimise intervention implementation for the main trial.Methods: Mixed methods process evaluation conducted in 14 UK hospitals between November 2016 and March 2018. Data included a site profile questionnaire and telephone scoping interview with hospital staff, 34 qualitative observations of standard care and 14 observations of intervention delivery, 13 semi-structured interviews with healthcare professionals (HCPs) and 28 semi-structured interviews with patients. Data analysis focused on describing intervention delivery within each arm, assessing fidelity, acceptability and how variation in delivery was linked to contextual characteristics.Results: Standard care exercise advice was typically limited to maintaining current activity levels, and with lead-in time to surgery affecting whether any exercise advice was provided. Variation in HCP capacity affected the ability of colorectal units to deploy staff to deliver the intervention. Patients’ exercise history and motivation prior to surgery influenced HCP perceptions and delivery of the motivational components. Observations indicated a high level of fidelity to delivery of the exercise interventions. All but one of the 28 interviewed patients reported increasing exercise levels as a result of receiving the intervention, with most finding them motivational and greatly valuing the enhanced level of social support (versus standard care) provided by staff.Conclusion: Hospital-supervised and home-based exercise interventions were highly acceptable for most patients undergoing surgery for CRC. Delivery of pre- and post-operative exercise within the CRC care pathway is feasible but systematic planning of capacity and resources is required to optimise implementation.

A qualitative evaluation of a multi-modal cancer prehabilitation programme for colorectal, head and neck and lung cancers patients

“…Success was mainly due to the visionary leadership and diverse and committed group of interdisciplinary professionals working together to adapt and refine a tailored stepped-care MCPP for local implementation at a Cancer Unit in Northern Ireland [14]. Current research investigating the feasibility and acceptability of MCPPs from the perspectives of professionals and patients is exceptionally limited [17] with studies often referring to patient recruitment and participation as indicators of success [23-24]. The findings from this study extend current evidence by illustrating the mechanisms of success and challenges experienced by those at SET and will be discussed through the lens of NPT components [20], coherence, cognitive participation, collective action and reflexive monitoring.…”

“…Murdoch et al . [17] study of their MCPP with a CRC patient group suggested that while professionals emphasised that fitness was important for surgery outcomes, patients were not encouraged to increase activity levels. Herein, they noted that the lack of exercise prescription was attributed to a short timeframe between diagnosis and treatment, plus constrained resources with clinicians being too busy [17].…”

“…[17] study of their MCPP with a CRC patient group suggested that while professionals emphasised that fitness was important for surgery outcomes, patients were not encouraged to increase activity levels. Herein, they noted that the lack of exercise prescription was attributed to a short timeframe between diagnosis and treatment, plus constrained resources with clinicians being too busy [17]. In contrast, the SET MCPP universal and targeted exercise prescription was delivered by MMCs within the local council setting who had capacity to deliver the programme components, yet exercise prescription was still considered to be lacking HIIT.…”

“…This would enable an enhanced understanding of processes and mechanisms leading to MCPP’s success and failure, paramount prior to scaling up and further roll-out [16]. To date, the authors are aware of only one MCPP qualitative feasibility study, however the focus was solely upon delivery fidelity and acceptability [17]. This novel paper aims to explore mechanisms promoting feasibility and acceptability of a MCPP from patients’ and professionals’ perspectives exploring planning, development and implementation phases.…”