Oncology Care Providers’ Awareness and Practice Related to Physical Activity Promotion for Breast Cancer Survivors and Barriers and Facilitators to Such Promotion: A Nationwide Cross-sectional Web-based Survey

doi:10.21203/rs.3.rs-693094/v1

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Research Article

Oncology Care Providers’ Awareness and Practice Related to Physical Activity Promotion for Breast Cancer Survivors and Barriers and Facilitators to Such Promotion: A Nationwide Cross-sectional Web-based Survey

https://doi.org/10.21203/rs.3.rs-693094/v1

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published 01 Dec, 2021

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Purpose

Lack of physical activity information provided by OCPs is a known barrier to getting breast cancer survivors (BCSs) to engage in habitual exercise. However, the actual situation in Japan remains unclear. This study sought to clarify OCPs’ awareness and practice related to Japan’s physical activity recommendation for BCSs and to ascertain barriers to these.

Methods

We conducted a web-based survey involving members of the Japanese Breast Cancer Society (JBCS) or the Japanese Association of Cancer Rehabilitation between Dec. 2018 and Feb. 2019.

Results

Of 10,830 members, 1,029 (9.5%) responded. Only 19.1% were aware of the details of the JBCS physical activity recommendation, and only 21.2% routinely provided physical activity information to BCSs. Barriers to routine provision were 1) absence of perceived work responsibility, 2) underestimation of survivors’ needs, 3) lack of resources, 4) lack of self-efficacy about the recommendation, and 5) poor knowledge of the recommendation. Factors related to being aware of the recommendation details were 1) availability of the guidelines, 2) experience reading relevant parts of the guidelines, and 3) involvement in multidisciplinary team case meetings.

Conclusions

Only one-fifth of the OCPs routinely provided physical activity information. Barriers to provision were poor awareness, self-efficacy, and attitudes and resource unavailability. The physical activity recommendation needs to be disseminated to all OCPs and a delivery system needs to be established for BCSs to receive appropriate information and support to promote engagement in habitual physical activity.

Cancer Biology

Oncology

Physical activity

breast cancer

cancer survivorship

dissemination and implementation sciences

clinical guidelines

Maintaining high physical activity level is known to play a role in extending the healthy lifespan of breast cancer survivors (BCSs) and to improving their health-related quality of life ^[1–5]. Accordingly, the American Cancer Society (ACS)/American Society of Clinical Oncology (ASCO) Breast Cancer Survivorship Guideline and the Japan Breast Cancer Society (JBCS) Clinical Practice Guidelines for systemic treatment of breast cancer strongly recommend that survivors maintain high physical activity levels ^[5–7]. However, many BCSs remain physically inactive ^[8–10].

One of the known patient-reported barriers to maintaining high physical activity levels is lack of information on physical activity provided by oncologists ^[11–13], despite cancer survivors having shown a strong preference for receiving such information from their oncologist ^{[14, 15]}. Several studies have reported that oncologists’ recommendations on exercise, or in combination with other interventions, increased patients’ physical activity levels ^[16–18]. Most oncologists still do not recommend physical activity to their patients, for various reasons including lack of time, being unclear about specific exercises to recommend, concerns about the effectiveness of exercise, patient safety, and poor knowledge about exercise ^[19–21]. Therefore, the role of discussing exercise recommendations with cancer survivors should be shared among multidisciplinary team members ^[21], not the oncologist alone, to increase survivors’ physical activity levels.

Promoting physical activity via a multidisciplinary team approach remains insufficient, however; despite several studies having reported that most cancer survivors would prefer to receive physical activity counseling or information from a fitness expert or physical activity specialist associated with a cancer center together with a health practitioner (i.e., specialist nurse, physician, or oncologist) ^[21]. To date, the barriers and facilitators to multidisciplinary team members routinely providing physical activity information have not been fully studied. Also, the amount of physical activity information that is actually provided by oncology care providers (OCPs) in Japan remains unclear. In order to assess the barriers and facilitators to OCPs systematically providing such information, in this study we used the Consolidated Framework for Implementation Research (CFIR), one of the most common frameworks for guiding systematic research that evaluates the process of implementing the delivery of health care ^[22–24].

The purpose of this study was threefold: 1) to determine OCPs’ awareness of the detailed contents of the JBCS physical activity recommendation, 2) to determine their routine provision of information about the JBCS physical activity recommendation to BCSs, and 3) to reveal the barriers and facilitators related to their awareness and provision.

Participants and procedures

We conducted a web-based self-report questionnaire survey using SurveyMonkey (SurveyMonkey, Palo Alto, CA) involving OCPs who were members of the JBCS (n = 9,996) or the Japanese Association of Cancer Rehabilitation (JACR, n = 834). Between Dec. 2018 and Feb. 2019, we sent an e-mail containing information on the research prospectus and the questionnaire link to each member on the societies’ mailing lists. The prospectus described the study’s purpose and method and method of consent (checking the “participation” box implied consent to participate), as well as contact information. We first asked them if they had completed the questionnaire of the other academic society, and then those who answered “Yes” couldn’t compete the subsequent questions. To improve the response rate, we sent three reminders to all. Those who regularly provided medical treatments or care to BCSs for over a 1-year period and were aged ≥ 20 years were included in the analysis. Those who could not respond to the self-reported questionnaire (written in Japanese) or did not answer any questions related to the study outcomes were excluded from the analysis.

Survey items

A literature review did not identify suitable tools with established reliability and validity for use in this study, so we developed an original questionnaire. We created the questionnaire items based on the results of a focus group interview with OCPs and a review of the literature using the CFIR. We also conducted cognitive checks with multidisciplinary research teams including oncologists who usually provide treatment or care for BCSs, rehabilitation therapists, oncology nurses, fitness trainers, BCSs, exercise physiologists, sports scientists, and psychiatrists.

The questionnaire consisted of 4 sections: (1) demographics, (2) awareness and practice related to the JBCS physical activity recommendation, (3) possible factors related to such awareness and practice, and (4) physical activity levels.

Participants were asked to provide socio-demographic information including age, sex, occupation, whether they were a manager or not, facility background, years of experience in breast cancer care, and frequency of medical care for BCSs.

Awareness and practice related to the JBCS physical activity recommendation were the outcome measures. For the question about awareness of the contents of the recommendation, we asked participants to select one of four options that most closely aligned with their experience: “I know its details”, “I may have heard about it, but I don’t know its details”, “I have heard of its existence”, or “I have never heard of it”. For the question about how often they inform BCSs about the benefits of physical activity in practice, they selected one of three options that most closely aligned with their experience: “I routinely explain the benefits of physical activity to breast cancer survivors”, “I occasionally explain the benefits of physical activity to breast cancer survivors”, or “I have never explained the benefits of physical activity to breast cancer survivors before”.

In terms of possible factors related to awareness and practice, we created the survey items according to the 4 subdomains of the CFIR. These consisted of 3 items on “intervention characteristics”, 5 on “outer setting”, 10 on “inner setting”, 10 on “characteristics of individuals”, and 3 on “process” (see Table 1).

Table 1. Demographic background of the participants and items from the CFIR

We also asked participants about their own physical activity levels using the Japan Public Health Center-based prospective study-physical activity questionnaire-short form (JPHC-PAQ-Short) ^[25], which has been validated ^{[25, 26]}. This is a 3-item scale: “heavy physical work or strenuous exercise” with 3 response options (“none”, “under 1 hour” and “1 hour or more”), “walking and standing” with 3 options (“under 1 hour”, “1–2 hours” and “3 hours or more”), and “sedentary activity” with 3 options (“3 hours or less”, “3–8 hours” and “8 hours or more”). Total physical activity levels were calculated according to the scale manual ^{[25, 26]}. We also asked participants to select 1 of 5 response options about their exercise habits in leisure time (“almost none” to “almost every day”).

Data analysis

We calculated descriptive statistics for OCPs’ awareness and practice related to the JBCS physical activity recommendation. Awareness of the recommendation was assessed as a binary variable according to whether or not they were aware of the details. The practice of providing the recommendation was assessed as a binary variable according to whether or not they regularly explained the benefits of physical activity to BCSs. To identify possible factors related to awareness and practice, we conducted logistic regression analysis with a backward elimination technique using each of the two dichotomous variables of awareness and practice as an outcome variable and with all relevant variables as explanatory variables.

All tests were two-tailed with a p value < 0.05 indicating statistical significance. All statistical analyses were performed using SAS Ver.9.4 (SAS Institute Inc., Cary, NC, USA).

Among the members of the JBCS, 912 (9.1%) responded to the survey and 892 (8.9%) answered the questions about awareness and practice related to the physical activity recommendation, and the corresponding numbers for the JACR were 159 (19.1%) and 137 (16.4%). The total number of subjects who were included as participants in the analysis was 1029 (9.5%) (Fig. 1).

Participant characteristics

Participant characteristics are summarized in Table 1. Overall, 54.6% of participants were male and the mean age was 48.0 (standard deviation: 9.8) years. The occupation of most of the participants was physician (70.6%), followed by nurse (11.7%) and rehabilitation therapist (11.9%). Most had experience caring for BCSs for 5 years or more and were caring for BCSs 5 or more times per week.

Participants’ awareness and practice related to the JBCS physical activity recommendation

Only 19.1% of participants knew the details of the JBCS physical activity recommendation, 48.6% had heard of it but did not know the details, and 20.1% had heard of it. In addition, only 21.2% routinely explained the benefits of physical activity to BCSs and 59.0% occasionally explained it (Fig. 2).

Items created using the CFIR

Intervention characteristics

Approximately half of the participants believed there was insufficient evidence for the effects of physical activity on breast cancer-related outcomes. Many participants felt efforts to promote physical exercise to BCSs to help them maintain high physical activity levels were too time-consuming and resource-consuming (Table 1).

Outer setting

Many participants (75%) recognized that more than 60% of BCSs needed support around physical activity. Few participants (14%) believed that more than 60% of BCSs are at high risk of adverse events like injury if they perform moderate-to-vigorous physical activity (MVPA). Only 9.8% of the participants reported that their facilities work with other facilities to help BCSs maintain high physical activity levels. Only 15% knew of any behavioral support efforts to maintain high physical activity for BSCs at other facilities (Table 1).

Inner setting

Approximately 40% of the participants had opportunities to consider survivorship care, including helping BSCs maintain high physical activity, in a multidisciplinary team. Half of them had already experienced clinical application of the revised JBCS guidelines or had confirmed their practice was in line with it. Only one-quarter of them had such learning opportunities. Regarding current resources available for BCSs to maintain physical activity levels at their facilities, 19% had some material, 0.6% had a website, and only 8.9% reported having any suitable environments or programs. Approximately 60% reported that the JBCS guidelines were available at their facilities (Table 1).

Characteristics of individuals

Approximately 70% had read the part about epidemiology and diagnosis in the revised JBCS guidelines. Overall, 91% wanted to inform breast cancer survivors so that they could maintain high physical activity levels, and 80% recognized that explaining the need to maintain high physical activity levels was within the scope of their profession’s work and also within the scope of services provided at their facilities. Approximately 60% were willing to take on leadership roles at their facilities for behavioral support initiatives to help BCSs maintain the recommended level of physical activity.

Approximately 90% knew that it is recommended for BCSs to maintain high physical activity levels. On the other hand, 25% did not know the recommended exercise intensity. Half of the respondents were not confident in informing BSCs about the physical activity recommendation and 75% had additional learning needs about the recommendation (Table 1).

Process

Only 14.4% reported that their facilities had outpatient nursing counseling services that included support for BCSs to maintain high physical activity levels, and 29% reported that their facilities had outpatient nursing counseling services that did not include such support. Although 68% reported their facilities had outpatient rehabilitation services, only 16% reported that these included such support.

Barriers and facilitators to participants’ awareness and practice related to the physical activity recommendation

The results of multivariate analysis (Table 2) showed that participants who tended to routinely explain the recommendation were characterized as follows: 1) perceived that helping BCSs to maintain high physical activity levels was within the scope of their profession’s work (odds ratio [OR]: 6.3, p < 0.01); 2) perceived that more than 60% of BCSs need help maintaining high physical activity levels (OR: 2.5, p < 0.01); 3) had high physical activity levels themselves (OR: 1.03, p = 0.003); 4) worked at facilities that had outpatient nursing counseling services that either included support for BSCs to maintain high physical activity levels (OR: 2.2) or did not include such support for maintaining high physical activity for breast cancer survivors (OR: 1.3), p = 0.01); 5) had self-efficacy in terms of informing BCSs about the physical activity recommendation (OR: 1.7, p < 0.01); 6) perceived that helping BCSs to maintain high physical activity levels is within the scope of their work responsibilities (OR: 1.9, p = 0.01); 7) knew details of the physical activity recommendation (OR: 1.7, p = 0.01); 8) had accurate knowledge of the recommended level of physical activity (OR: 1.8, p = 0.02); and 9) worked at facilities that had any suitable environments or programs to help BCSs maintain high physical activity levels (OR: 1.9, p = 0.04).

Table 2. Barriers and facilitators to oncology care providers' routinely explaining the physical activity recommendation in the JBCS revised guidelines.

Logistic regression analysis with backward elimination (p<0.05); R2=0.16, modified R2=0.25 c statistics=0.77

JBCS: Japan Breast Cancer Survivor, JACR: Japanese Association of Cancer Rehabilitation, BCS: Breast Cancer Survivor, CFIR: Consolidated Framework for Implementation Research, MVPA: Modertate to vigorous physical activity

OR: Odds ratio, Ci: Confidence interval, ref: reference

Participants who tended to know the details of the physical activity recommendation were as follows (Table 3): 1) had already read the part about epidemiology and diagnosis in the revised guidelines (OR: 7.4, p < 0.01); 2) had self-efficacy in terms of informing BSCs about the physical activity recommendation (OR: 2.9, p < 0.01); 3) perceived that helping BCSs to maintain high physical activity was within the scope of their profession’s work (OR: 3.1, p < 0.01); 4) worked at facilities that had outpatient nursing counseling services that included support BCSs to maintain high physical activity levels (OR: 2.0) or did not include such support (OR: 1.05, p = 0.04); 5) perceived that there was solid evidence for the physical activity recommendation (OR: 1.8, p = 0.01); 6) had the opportunity to discuss survivorship care for BCSs in a multidisciplinary team (OR: 1.6, p = 0.02); 7) worked at facilities where the JBCS guidelines were available (OR: 1.7, p = 0.04); and 8) had accurate knowledge of the recommended levels of physical activity (OR: 1.8, p = 0.048).

Table 3. Barriers and facilitators to oncology care providers' awareness of the details of the physical activity recommendation of the JBCS revised guidelines.

Logistic regression analysis with backward elimination (p < 0.05). R2 = 0.17, modified R2 = 0.28, c statistics = 0.81 JBCS: Japan Breast Cancer Survivor, JACR: Japanese Association of Cancer Rehabilitation, BCS: Breast Cancer Survivor, CFIR: Consolidated Framework for Implementation Research, MVPA: Modertate to vigorous physical activity OR: Odds ratio, Ci: Confidence interval, ref: reference

This is the first study to clarify OCPs’ awareness and practice related to the physical activity recommendation for BCSs in the JBCS guidelines. Even though cancer survivors show a strong preference for receiving information about exercise behavior from their oncologist ^{[14, 15]}, only 21.2% of the OCPs in the present study routinely tell BSCs about the physical activity recommendation.

Among the OCPs in this study, one of the most significant related factors in deciding whether or not to routinely explain the physical activity recommendation to BCSs was their perception about the scope of work responsibilities in their own profession. Notably, those who thought provision of physical activity information was not within the scope of their profession’s work or of the scope of their own duty at their facility did not implement delivery of the recommendation. Therefore, an approach is needed that recognizes providing information on physical activity is a part of care in daily practice.

OCPs who did not recognize that more than 60% of BCSs need help maintaining high physical activity levels tended not to routinely explain the physical activity recommendation. We estimate that around 60% of BCSs may need physical activity support given that 35% of BCSs met the JBCS physical activity recommendation in our other study, which is currently being prepared for submission ^[27]. Thus, is important to inform OCPs that there are many BCSs who potentially need help in maintaining high physical activity levels because they do not meet the JBCS recommendation.

OCPs who worked at facilities with available resources tended to routinely explain the physical activity recommendation more than those who worked at facilities without such resources. On the other hand, 68% perceived provision of the physical activity recommendation as time-consuming and 57% perceived it as resource-consuming. Thus, lack of time and lack of available resources are barriers to these providers routinely explaining the recommendation. This result is similar to that of previous studies ^{[19, 21]}. In the present study, 29% reported that their facilities had outpatient nursing counseling services that did not include support for BCSs to maintaining high physical activity levels and 51% reported that their facilities had outpatient rehabilitation services that did not include such support. There might be potential for these facilities to offer outpatient nursing and rehabilitation services that include such support. As only 9.8% answered that they are currently cooperation with other facilities in the area, promoting collaboration with surrounding facilities may be an option to compensate for the lack of available resources. Proposing specific exercise programs to BCSs will likely be difficult in practice due to limited time and resources. To help address this, we have developed a home-based exercise program for BCSs that does not require the use of special tools and can be completed in a short time ^[28].

In this study, self-efficacy was one of the most significant facilitators in the routine provision of the physical activity recommendation. However, self-efficacy was evident in approximately half of the respondents, and around 75% wanted additional training and study sessions. We suggest that all OCPs be told specifically about the recommendation to provide them the necessary knowledge and skills to implement it and thereby improve efficacy expectation ^{[29, 30]}. On the other hand, the outcome expectation is also important to consider. About half of respondents thought the evidence for the physical activity recommendation was not sufficient. In this study and a previous study by Park et al. ^[19–21], concerns about the effectiveness of exercise were barriers to recommending exercise for cancer survivors. Therefore, further research is needed to determine whether or not increased physical activity and fitness through exercise interventions improves breast cancer-related outcomes.

Factors related to the provision of the physical activity recommendation were awareness of its details and accurate knowledge of the recommended level of physical activity. This finding is similar to a previous study that showed OCPs’ poor knowledge was one of the most significant barriers to exercise discussion ^[21]. Factors related to being aware of the details of the physical activity recommendation were the same as some of the related factors for provision of the recommendation. Besides these common factors, the related factors of being aware of the recommendation details were 1) availability of the JBCS guidelines at the facility, 2) experience reading the relevant part in the revised guidelines, and 3) opportunity to discuss survivorship care in a multidisciplinary team. Given related factor 2), it will be important to promote the revised guidelines in collaboration with academic societies. Discussing survivorship care in a multidisciplinary team is thought to encourage understanding of the relevant evidence and guidelines, and we suggest offering such opportunities. Furthermore, experience of reviewing and revising daily practice in accordance with the revised JBCS guidelines tended to be a facilitator to awareness of the recommendation details in our bivariate analysis (Table 3), so we also recommend creating a culture that confirms daily practice based on the evidence provided in the guidelines.

As reported previously ^{[19, 21]}, OCPs with higher physical activity levels themselves tended to provide physical activity information to patients. It can be inferred that the OCPs with similar levels might have had a positive view of the health effects of physical activity, and as a result tended to explain these effects more positively to cancer survivors than OCPs with lower physical activity levels. Further research is needed to confirm the validity of this speculation.

There were several limitations in this study. The results cannot be generalized to all OCPs. There could have been participation bias because the response rates were low (JBCS:8.9% and JACR:16.4%) and those who volunteered to participate might have had a strong interest in the physical activity recommendation.

We clarified that only one-fifth of OCPs routinely provide physical activity information and only 19.1% of them are aware of the detailed contents of the JBCS physical activity recommendation. Barriers to their routine provision of the physical activity recommendation were 1) perception that the recommendation was not within the scope of their work responsibilities, 2) underestimation of survivors’ physical activity needs, 3) lack of resources, and 4) lack of self-efficacy and 5) poor knowledge of the recommendation. In addition, the related factors of being aware of the details of the recommendation were 1) availability of the JBCS guidelines at the facility, 2) experience reading the part about epidemiology and diagnosis in the guidelines, and 3) opportunity to discuss survivorship care for survivors in a multidisciplinary team.

Thus, to facilitate implementation of the provision of the physical activity recommendation, we suggest the following actions: 1) disseminate the JBCS revised guidelines to all OCPs, 2) provide education and training programs for OCPs about promoting physical activity, 3) develop institutional resources and/or strengthening collaboration with surrounding resources for maintaining high physical activity in BCSs, 4) conduct further research to confirm the benefits of physical activity for BCSs in the Japanese population, and 5) develop programs to help BCSs maintain high physical activity levels that are less costly in terms of time and resources than those currently available. In addition, conducting case meetings in a multidisciplinary team and reviewing clinical practice based on evidence will enhance dissemination and implementation of the guidelines.

Acknowledgments

We are grateful to Professor Shigeru Imoto, President of the JBCS, and Professor Tetsuya Tsuji, President of the JACR, and the members of the associations who have made efforts in recruiting the participants. We thank all participants in the focus group interviews, which led to the development of the survey items. We also thank Ms. Noriko Watanabe and Dr. Hikaru Ihira for their generous support of the study.　We also thank National Center Consortium in Implementation Science for Health Equity (N-EQUITY) for providing their knowledge on dissemination implementation science research.

Funding

This study was supported by a National Cancer Center Research and Development Fund (30-A-17).

Conflict of interest/Competing interests

EO has received research support from Nippon Suisan Kaisha, Ltd. YJM has received speaker fees from Suntory Wellness, Pfizer, Mochida, Eli Lilly, Morinaga Milk, and Cimic and is conducting collaborative research with Susmed. AK has received speaking fees from Chugai Pharmaceutical Co., Ltd. All other authors declare that they have no competing interests regarding this work.

Availability of data and material

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Code availability

Not applicable.

Authors’ contributions

YS, KT, EO, RO, HI, and YM conceived the study and drafted the original protocol. YS, KT, EO, RO, TS, NS, AK, HI, and YM contributed to developing the survey questionnaire. AK played a major role in statistical analysis. All authors participated in, read, and approved the final manuscript.

Ethics approval

This survey of OCPs did not collect identifying personal information or ask invasive questions. The institutional review board of the National Cancer Center Japan waived the need for ethics review. We conducted the survey with approval of the chair of the National Cancer Center Japan and the academic committee of the JBCS. We conducted the survey in accordance with the policies outlined in relevant ethical guidelines such as the Declaration of Helsinki, with due consideration given to the protection of individuals.

Consent to participate

Consent to participate was obtained by ticking the check-box with providing the appropriate prospectus.

Consent for publication

All authors consent to publication of this article in Supportive Care in Cancer.

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Oncology Care Providers’ Awareness and Practice Related to Physical Activity Promotion for Breast Cancer Survivors and Barriers and Facilitators to Such Promotion: A Nationwide Cross-sectional Web-based Survey

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