The use of cardiac rehabilitation services to aid the recovery of patients with bowel cancer: a pilot randomised controlled trial with embedded feasibility study

Abstract

Background: Colorectal cancer (CRC) survivors are not meeting the recommended physical activity levels associated with improving their chances of survival and quality of life. Rehabilitation could address this problem. Objectives: The aims of the Cardiac Rehabilitation In Bowel cancer study were to assess whether or not cardiac rehabilitation is a feasible and acceptable model to aid the recovery of people with CRC and to test the feasibility and acceptability of the protocol design. Design: Intervention testing and feasibility work (phase 1) and a pilot randomised controlled trial with embedded qualitative study (phase 2), supplemented with an economic evaluation. Randomisation was to cardiac rehabilitation or usual care. Outcomes were differences in objective measures of physical activity and sedentary behaviour, self-reported measures of quality of life, anxiety, depression and fatigue. Qualitative work involved patients and clinicians from both cancer and cardiac specialties. Setting: Three colorectal cancer wards and three cardiac rehabilitation facilities. Participants: Inclusion criteria were those who were aged > 18 years, had primary CRC and were post surgery. Results: Phase 1 (single site) – of 34 patient admissions, 24 (70%) were eligible and 4 (17%) participated in cardiac rehabilitation. Sixteen clinicians participated in an interview/focus group. Modifications to trial procedures were made for further testing in phase 2. Additionally, 20 clinicians in all three sites were trained in cancer and exercise, rating it as excellent. Phase 2 (three sites) – screening, eligibility, consent and retention rates were 156 (79%), 133 (67%), 41 (31%) and 38 (93%), respectively. Questionnaire completion rates were 40 (97.5%), 31 (75%) and 25 (61%) at baseline, follow-up 1 and follow-up 2, respectively. Forty (69%) accelerometer data sets were analysed; 20 (31%) were removed owing to invalid data. Qualitative study: CRC and cardiac patients and clinicians were interviewed. Key themes were benefits and barriers for people with CRC attending cardiac rehabilitation; generic versus disease-specific rehabilitation; key concerns of the intervention; and barriers to participation (CRC participants only). Economic evaluation: The average out-of-pocket expenses of attending cardiac rehabilitation were £50. The costs of cardiac rehabilitation for people with cancer are highly dependent on whether it involves accommodating additional patients in an already existing service or setting up a completely new service. Limitations and conclusions: The main limitation is that this is a small feasibility and pilot study. The main novel finding is that cardiac rehabilitation for cancer and cardiac patients together is feasible and acceptable, thereby challenging disease-specific rehabilitation models. Future work: This study highlighted important challenges to doing a full-scale trial of cardiac rehabilitation but does not, we believe, provide sufficient evidence to reject the possibility of such a future trial. We reco...

The Effect of Exercise-Based Cardiac Rehabilitation on Objectively Measured Physical Activity and Sedentary Behavior: A Systematic Review and Meta-analysis

“…A detailed description of the design and participant characteristics in each study appears in Table 1. Of the included studies, 4 were prospective cohort studies 25-28 and 11 were randomized controlled trials 29-39 published between 2004 and 2019. The study by Ribeiro et al 35 was a subanalysis of 2 randomized controlled trials.…”

“…Three studies were conducted in the Netherlands, 28,36,37 2 in Portugal, 33,35 2 in Belgium, 31,32 2 in the United States, 27,39 2 in Canada, 26,34 1 in Australia, 25 2 in the United Kingdom, 30,38 and 1 in Sweden. 29 The patient profile within the studies included patients with heart failure (mostly systolic dysfunction, NYHA [New York Heart Association] class II and III) with reduced or preserved ejection fraction, 29,30,37,38 those who had been diagnosed with coronary artery disease, ischemic heart disease, and/or acute coronary syndrome and who were treated for such including via coronary artery bypass grafting or revascularization surgery. 25-28,31-36,39…”

“…Using SMDs allowed the studies to be combined on a uniform scale to account for variability observed in each study (ie, difference in mean outcome/standard deviation of the outcome). Within studies that had more than one intervention, 26,36 or follow-up period, 25,26,30,36 each intervention was entered into the meta-analysis separately. Effect sizes associated with these SMDs were allocated as follows: >0.8 large, 0.5 to 0.79 moderate, and 0.2 to 0.49 a weak effect.…”

“…The duration of CR exercise programs ranged from 4 to 8 weeks with a frequency of visits between 2 and 3 times per week. Nine out of the 15 studies included a follow-up after the intervention, 25,28,[30][31][32]36,38,39 which ranged between 18 weeks and 18 months. Exercise sessions lasted between 15 and 60 minutes.…”

“…25,27,28,31,34 Ten studies incorporated education and counseling sessions on improving lifestyles, PA and its consequences, strategies on improving PA and improving lifestyle and diet (Figure 2). 25,26,28,[30][31][32][34][35][36]38,39 All but 2 studies 29,36 reported intervention compliance results.…”