Publications by authors named "Liam Bourke"

40 Publications

Embedding supervised exercise training for men on androgen deprivation therapy into standard prostate cancer care: a feasibility and acceptability study (the STAMINA trial).

Sci Rep 2021 06 14;11(1):12470. Epub 2021 Jun 14.

Allied Health Professionals, Radiotherapy and Oncology, Sheffield Hallam University, Sheffield, UK.

Lifestyle interventions involving exercise training offset the adverse effects of androgen deprivation therapy in men with prostate cancer. Yet provision of integrated exercise pathways in cancer care is sparse. This study assessed the feasibility and acceptability of an embedded supervised exercise training intervention into standard prostate cancer care in a single-arm, multicentre prospective cohort study. Feasibility included recruitment, retention, adherence, fidelity and safety. Acceptability of behaviourally informed healthcare and exercise professional training was assessed qualitatively. Despite the imposition of lockdown for the COVID-19 pandemic, referral rates into and adherence to, the intervention was high. Of the 45 men eligible for participation, 79% (n = 36) received the intervention and 47% (n = 21) completed the intervention before a government mandated national lockdown was enforced in the United Kingdom. Patients completed a mean of 27 min of aerobic exercise per session (SD = 3.48), at 77% heart rate maximum (92% of target dose), and 3 sets of 10 reps of 3 resistance exercises twice weekly for 12 weeks, without serious adverse event. The intervention was delivered by 26 healthcare professionals and 16 exercise trainers with moderate to high fidelity, and the intervention was deemed highly acceptable to patients. The impact of societal changes due to the pandemic on the delivery of this face-to-face intervention remain uncertain but positive impacts of embedding exercise provision into prostate cancer care warrant long-term investigation.
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http://dx.doi.org/10.1038/s41598-021-91876-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203669PMC
June 2021

The development of a theory and evidence-based intervention to aid implementation of exercise into the prostate cancer care pathway with a focus on healthcare professional behaviour, the STAMINA trial.

BMC Health Serv Res 2021 Mar 25;21(1):273. Epub 2021 Mar 25.

Institute for Population Health Sciences, Queen Mary, University of London, London, UK.

Background: Twice-weekly supervised aerobic and resistance exercise for 12 weeks reduces fatigue and improves quality of life in men on Androgen Deprivation Therapy for prostate cancer. Despite the National Institute for Health and Care Excellence (NICE) proposing this as standard of care, it does not routinely take place in practice. Healthcare professionals are in a prime position to deliver and integrate these recommendations. A change in the behaviour of clinical teams is therefore required. In this paper, we describe the development of a training package for healthcare professionals using theory and evidence to promote delivery of such recommendations as standard care.

Methods: The intervention development process was guided by the Medical Research Council guidance for complex interventions and the Behaviour Change Wheel. Target behaviours were identified from the literature and thirty-five prostate cancer care healthcare professionals (including oncologists, consultant urologists, clinical nurse specialists, physiotherapists, general practitioners and commissioners) were interviewed to understand influences on these behaviours. The Theoretical Domains Framework was used to identify theoretical constructs for change. Behaviour change techniques were selected based on theory and evidence and were translated into intervention content. The intervention was refined with the input of stakeholders including healthcare professionals, patients, and exercise professionals in the form of rehearsal deliveries, focus groups and a workshop.

Results: Seven modifiable healthcare professional target behaviours were identified to support the delivery of the NICE recommendations including identifying eligible patients suitable for exercise, recommending exercise, providing information, exercise referral, providing support and interpret and feedback on progress. Ten domains from the Theoretical Domain's Framework were identified as necessary for change, including improving knowledge and skills, addressing beliefs about consequences, and targeting social influences. These were targeted through twenty-two behaviour change techniques delivered in a half-day, interactive training package. Based on initial feedback from stakeholders, the intervention was refined in preparation for evaluation.

Conclusions: We designed an intervention based on theory, evidence, and stakeholder feedback to promote and support the delivery of NICE recommendations. Future work will aim to test this training package in a multi-centre randomised trial. If proven effective, the development and training package will provide a template for replication in other clinical populations, where exercise has proven efficacy but is insufficiently implemented.
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http://dx.doi.org/10.1186/s12913-021-06266-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7992804PMC
March 2021

Remote interventions to improve exercise behaviour in sedentary people living with and beyond cancer: a systematic review and meta-analysis.

BMC Cancer 2021 Mar 24;21(1):308. Epub 2021 Mar 24.

College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK.

Background: The COVID-19 pandemic has forced many cancer services to consider a transition to a remote format of delivery that is largely untested. Accordingly, we sought to perform a systematic review of the effects of remotely delivered interventions to improve exercise behaviour in sedentary adults living with and beyond cancer.

Methods: Eligible studies were randomised controlled trials comparing a remotely delivered exercise intervention to a usual care comparison in sedentary people over 18 years old with a primary cancer diagnosis. Nine electronic databases were searched from inception to November 2020.

Results: The review included three trials, totalling 186 participants. Two of the included trials incorporated prescriptions that meet current aerobic exercise recommendations, one of which also meets the guidelines for resistance exercise. No trials reported an intervention adherence of 75% or more for a set prescription that meets current exercise guidelines.

Conclusion: There is little evidence suggesting that remote exercise interventions promote exercise behaviours or improve physical function in sedentary adults living with and beyond cancer. The development and evaluation of novel remote exercise interventions is needed to establish their usefulness for clinical practice. Given the social response to the COVID-19 pandemic, further research in this area is urgently needed.
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http://dx.doi.org/10.1186/s12885-021-07989-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987748PMC
March 2021

Towards implementing exercise into the prostate cancer care pathway: development of a theory and evidence-based intervention to train community-based exercise professionals to support change in patient exercise behaviour (The STAMINA trial).

BMC Health Serv Res 2021 Mar 22;21(1):264. Epub 2021 Mar 22.

Institute for Population Health Sciences, Queen Mary University of London, London, UK.

Background: The National Institute for Health and Care Excellence (NICE) recommend that men on androgen deprivation therapy (ADT) for prostate cancer should receive supervised exercise to manage the side-effects of treatment. However, these recommendations are rarely implemented into practice. Community-based exercise professionals (CBEPs) represent an important target group to deliver the recommendations nationally, yet their standard training does not address the core competencies required to work with clinical populations, highlighting a need for further professional training. This paper describes the development of a training package to support CBEPs to deliver NICE recommendations.

Methods: Development of the intervention was guided by the Medical Research Council guidance for complex interventions and the Behaviour Change Wheel. In step one, target behaviours, together with their barriers and facilitators were identified from a literature review and focus groups with CBEPs (n = 22) and men on androgen deprivation therapy (n = 26). Focus group outputs were mapped onto the Theoretical Domains Framework (TDF) to identify theoretical constructs for change. In step two, behaviour change techniques and their mode of delivery were selected based on psychological theories and evidence to inform intervention content. In step three, the intervention was refined following delivery and subsequent feedback from intervention recipients and stakeholders.

Results: Six modifiable CBEPs target behaviours were identified to support the delivery of the NICE recommendations. Nine domains of the TDF were identified as key determinants of change, including: improving knowledge and skills and changing beliefs about consequences. To target the domains, we included 20 BCTs across 8 training modules and took a blended learning approach to accommodate different learning styles and preferences. Following test delivery to 11 CBEPs and feedback from 28 stakeholders, the training package was refined.

Conclusion: Established intervention development approaches provided a structured and transparent guide to intervention development. A training package for CBEPs was developed and should increase trust amongst patients and health care professionals when implementing exercise into prostate cancer care. Furthermore, if proven effective, the development and approach taken may provide a blueprint for replication in other clinical populations where exercise has proven efficacy but is insufficiently implemented.
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http://dx.doi.org/10.1186/s12913-021-06275-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982309PMC
March 2021

Clinical outcomes and epidemiology of intraocular foreign body injuries in Cork University Hospital, Ireland: an 11-year review.

Ir J Med Sci 2021 Aug 23;190(3):1225-1230. Epub 2020 Nov 23.

Ophthalmology Department, Cork University Hospital, Wilton, Cork, T12DC4A, Ireland.

Background/aims: To describe the epidemiology, outcomes, and prognostic factors of intraocular foreign body (IOFB) injuries at a tertiary ophthalmic referral centre in Cork University Hospital, Ireland.

Methods: A retrospective review of 23 eyes with IOFB that presented to Cork University Hospital (CUH) from January 2009 to December 2019 was performed. The mechanism and characteristics of IOFB injury were all noted. This data was collated and analysed to ascertain the epidemiology of IOFB injury in CUH and to describe the prognostic factors affecting visual outcome following IOFB injury.

Results: There was a 100% male prevalence. The mean age was 37.4 years. The majority of IOFBs were metal in nature and were acquired by hammering, often while working and frequently in the absence of personal protective equipment (PPE). The route of entry for the IOFB was via the cornea in 70% of cases. Fifty-two percent of cases were clinically detectable and 43% of cases were only identifiable on CT (computed tomography) imaging. Eighty-seven percent of cases underwent surgery on the same day as presentation. There was no incidence (0%) of endophthalmitis. Seventeen percent of cases developed post-operative retinal detachment (RD). The mean pre-operative VA was 0.79 LogMAR (6/38 Snellen equivalent-SE) compared to a mean VA of 0.58 LogMAR (6/24 SE) following surgery.

Conclusions: This review provides important epidemiological data for IOFB injuries in Ireland. It also adds some useful information to the literature in relation to prognostic factors and lens status post IOFB injury.
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http://dx.doi.org/10.1007/s11845-020-02443-9DOI Listing
August 2021

2020 Vision? A case of malignant hypertension.

BMJ Case Rep 2020 Aug 25;13(8). Epub 2020 Aug 25.

Department of Cardiology, Cork University Hospital Group, Cork, Ireland.

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http://dx.doi.org/10.1136/bcr-2020-236617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7449352PMC
August 2020

Cardiovascular Disease and the Androgen Receptor: Here We Go Again?

Eur Urol 2020 02 28;77(2):167-169. Epub 2019 Aug 28.

Sheffield Hallam University, Sheffield, UK.

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http://dx.doi.org/10.1016/j.eururo.2019.08.017DOI Listing
February 2020

Interventions for promoting habitual exercise in people living with and beyond cancer.

Cochrane Database Syst Rev 2018 09 19;9:CD010192. Epub 2018 Sep 19.

Centre for Sport and Exercise Science, Sheffield Hallam University, A124 Collegiate Hall, Collegiate Crescent, Sheffield, South Yorkshire, UK, S10 2BP.

Background: This is an updated version of the original Cochrane Review published in the Cochrane Library 2013, Issue 9. Despite good evidence for the health benefits of regular exercise for people living with or beyond cancer, understanding how to promote sustainable exercise behaviour change in sedentary cancer survivors, particularly over the long term, is not as well understood. A large majority of people living with or recovering from cancer do not meet current exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important for understanding the most effective strategies to ensure benefit in the patient population and identify research gaps.

Objectives: To assess the effects of interventions designed to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following secondary questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals and/or healthcare professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with better behavioural outcomes? What behaviour change techniques (BCTs) are most often associated with increased exercise behaviour? What adverse effects are attributed to different exercise interventions?

Search Methods: We used standard methodological procedures expected by Cochrane. We updated our 2013 Cochrane systematic review by updating the searches of the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, Embase, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro up to May 2018. We also searched the grey literature, trial registries, wrote to leading experts in the field and searched reference lists of included studies and other related recent systematic reviews.

Selection Criteria: We included only randomised controlled trials (RCTs) that compared an exercise intervention with usual care or 'waiting list' control in sedentary people over the age of 18 with a homogenous primary cancer diagnosis.

Data Collection And Analysis: In the update, review authors independently screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that could not be safely excluded without assessment of the full text (e.g. when no abstract is available). We extracted data from all eligible papers with at least two members of the author team working independently (RT, LS and RG). We coded BCTs according to the CALO-RE taxonomy. Risk of bias was assessed using the Cochrane's tool for assessing risk of bias. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. If statistical heterogeneity was noted, a meta-analysis was performed using a random-effects model. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation (SD) of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate the standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we narratively synthesised studies. The quality of the evidence was assessed using the GRADE approach with the GRADE profiler.

Main Results: We included 23 studies in this review, involving a total of 1372 participants (an addition of 10 studies, 724 participants from the original review); 227 full texts were screened in the update and 377 full texts were screened in the original review leaving 35 publications from a total of 23 unique studies included in the review. We planned to include all cancers, but only studies involving breast, prostate, colorectal and lung cancer met the inclusion criteria. Thirteen studies incorporated a target level of exercise that could meet current recommendations for moderate-intensity aerobic exercise (i.e.150 minutes per week); or resistance exercise (i.e. strength training exercises at least two days per week).Adherence to exercise interventions, which is crucial for understanding treatment dose, is still reported inconsistently. Eight studies reported intervention adherence of 75% or greater to an exercise prescription that met current guidelines. These studies all included a component of supervision: in our analysis of BCTs we designated these studies as 'Tier 1 trials'. Six studies reported intervention adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendations: in our analysis of BCTs we designated these studies as 'Tier 2 trials.' A hierarchy of BCTs was developed for Tier 1 and Tier 2 trials, with programme goal setting, setting of graded tasks and instruction of how to perform behaviour being amongst the most frequent BCTs. Despite the uncertainty surrounding adherence in some of the included studies, interventions resulted in improvements in aerobic exercise tolerance at eight to 12 weeks (SMD 0.54, 95% CI 0.37 to 0.70; 604 participants, 10 studies; low-quality evidence) versus usual care. At six months, aerobic exercise tolerance was also improved (SMD 0.56, 95% CI 0.39 to 0.72; 591 participants; 7 studies; low-quality evidence).

Authors' Conclusions: Since the last version of this review, none of the new relevant studies have provided additional information to change the conclusions. We have found some improved understanding of how to encourage previously inactive cancer survivors to achieve international physical activity guidelines. Goal setting, setting of graded tasks and instruction of how to perform behaviour, feature in interventions that meet recommendations targets and report adherence of 75% or more. However, long-term follow-up data are still limited, and the majority of studies are in white women with breast cancer. There are still a considerable number of published studies with numerous and varied issues related to high risk of bias and poor reporting standards. Additionally, the meta-analyses were often graded as consisting of low- to very low-certainty evidence. A very small number of serious adverse effects were reported amongst the studies, providing reassurance exercise is safe for this population.
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http://dx.doi.org/10.1002/14651858.CD010192.pub3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513653PMC
September 2018

Supportive interventions to improve physiological and psychological health outcomes among patients undergoing cystectomy: a systematic review.

BMC Urol 2018 Aug 24;18(1):71. Epub 2018 Aug 24.

Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK.

Background: Our understanding of effective perioperative supportive interventions for patients undergoing cystectomy procedures and how these may affect short and long-term health outcomes is limited.

Methods: Randomised controlled trials involving any non-surgical, perioperative interventions designed to support or improve the patient experience for patients undergoing cystectomy procedures were reviewed. Comparison groups included those exposed to usual clinical care or standard procedure. Studies were excluded if they involved surgical procedure only, involved bowel preparation only or involved an alternative therapy such as aromatherapy. Any short and long-term outcomes reflecting the patient experience or related urological health outcomes were considered.

Results: Nineteen articles (representing 15 individual studies) were included for review. Heterogeneity in interventions and outcomes across studies meant meta-analyses were not possible. Participants were all patients with bladder cancer and interventions were delivered over different stages of the perioperative period. The overall quality of evidence and reporting was low and outcomes were predominantly measured in the short-term. However, the findings show potential for exercise therapy, pharmaceuticals, ERAS protocols, psychological/educational programmes, chewing gum and nutrition to benefit a broad range of physiological and psychological health outcomes.

Conclusions: Supportive interventions to date have taken many different forms with a range of potentially meaningful physiological and psychological health outcomes for cystectomy patients. Questions remain as to what magnitude of short-term health improvements would lead to clinically relevant changes in the overall patient experience of surgery and long-term recovery.
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http://dx.doi.org/10.1186/s12894-018-0382-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109292PMC
August 2018

A multi-centre investigation of delivering national guidelines on exercise training for men with advanced prostate cancer undergoing androgen deprivation therapy in the UK NHS.

PLoS One 2018 5;13(7):e0197606. Epub 2018 Jul 5.

Department of Oncology and Metabolism, University of Sheffield, Sheffield United Kingdom.

Background: National guidelines (NICE-CG175) recommended 12 weeks of supervised exercise training for men treated with androgen deprivation therapy (ADT) for prostate cancer to counter debilitating adverse effects of castration. As with other chronic conditions where exercise is indicated, it is uncertain if these services are being delivered in the health services. The aim of this multi-centre investigation was to examine what exercise referral is currently available for men on ADT as provided by the NHS and if a supervised, individually-tailored exercise training package (as per the national NICE guidelines CG175) is embedded within prostate cancer care.

Methods: A multi-centre investigation of current National Health Service (NHS) care involving a web-based survey of NHS prostate cancer care, five focus groups involving 26 men on ADT and 37 semi-structured interviews with healthcare professionals (HCPs) involved in the management of prostate cancer. Descriptive statistics and thematic analysis evaluated quantitative and qualitative data, respectively. Qualitative methods followed COREQ standards.

Results: HCPs and men on ADT asserted that medical castration has a serious and debilitating impact on many features of men's quality of life. There is support for exercise training programmes as part of cancer care and patients would support their initiation soon after diagnosis. Involving the Multidisciplinary Team (MDT) is proposed as key to this. Critically, traditional values in oncology would need to be overcome for widespread acceptance. Specialist further training for HCPs around behaviour change support could encourage this. Given that these schemes are seen as a fundamental part of cancer care, it is felt the NHS should commission and support provision. 79 representatives of 154 NHS trusts (51%) provided survey data on current delivery: only 17% could provide supervised exercise as per CG175.

Conclusions: Evidence-based national exercise guidelines are not being delivered to men on ADT as intended. Traditional values in oncology and the need for NHS financial support are seen as major barriers to provision of current best practice guidelines. Despite this both HCPs and men on ADT are in favour of such programmes being a fundamental part of their cancer care.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0197606PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033384PMC
December 2018

Clinical and Laboratory Biomarkers for Pseudoexfoliation Syndrome.

J Glaucoma 2018 07;27 Suppl 1:S111-S113

Institute of Ophthalmology, Mater Misericordiae University Hospital, Dublin, Ireland.

In this review, we present an update on biomarkers (both clinical and laboratory) on the basis of recent peer-reviewed publications relating to pseudoexfoliation syndrome and pseudoexfoliation glaucoma.
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http://dx.doi.org/10.1097/IJG.0000000000000924DOI Listing
July 2018

Treatment in the STAMPEDE era for castrate resistant prostate cancer in the UK: ongoing challenges and underappreciated clinical problems.

BMC Cancer 2018 Jun 19;18(1):667. Epub 2018 Jun 19.

The Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK.

Background: This study aimed to explore the opinions of healthcare professionals regarding the management of men with advanced prostate cancer with particular emphasis on treatment timing and sequencing; treatment adverse-effects and exercise a supportive therapy.

Methods: Semi-structured interviews with a purposively selected group of healthcare professionals involved in prostate cancer care within the NHS, conducted over the phone or face to face. A total of 37 healthcare professionals participated in the interviews including urologists, clinical oncologists, medical oncologists, clinical nurse specialists, general practitioners, physiotherapists, exercise specialists, service managers, clinical commissioners and primary care physicians.

Results: The availability of newer treatments for advanced prostate cancer as well as results from the STAMPEDE and CHAARTED trials has resulted in new challenges for patients and HCPs. This includes the impact of an increased workload on oncologists, a potential lack of clinical continuity between urology and oncology and uncertainties regarding optimal selection, timing and sequencing of chemotherapy and second-line treatment. Fitness for treatment in advanced prostate cancer populations remains a significant barrier to accessing therapies for patients with a poor performance status. Among this, muscle wastage can significantly affect performance status and consequentially compromise cancer therapy. Exercise was regarded as a potential therapy to mitigate the adverse-effects of treatment including the prevention or reduction in muscle wastage.

Conclusions: There is a lack of data guiding clinicians in this post STAMPEDE and CHAARTED era, work is needed to reassess and optimize the prostate cancer care pathway as it evolves. Exercise should be explored as a therapeutic option to mitigate the effects of long term ADT. Further study from a wider cohort of both prostate cancer care specialists and patients will aid in establishing a highly functioning pathway with optimal individualised care.

Trial Registration: Sustained exercise TrAining for Men wIth prostate caNcer on Androgen deprivation: the STAMINA programme (RP-DG-1213-10,010). REC Reference: 15/SW/0260 IRAS Project ID: 178340 Hospital ID: STH 18391 approved on 24/08/2015.
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http://dx.doi.org/10.1186/s12885-018-4527-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6006691PMC
June 2018

Review of systematic reviews of non-pharmacological interventions to improve quality of life in cancer survivors.

BMJ Open 2017 Nov 28;7(11):e015860. Epub 2017 Nov 28.

Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.

Objectives: Over two million people in the UK are living with and beyond cancer. A third report diminished quality of life.

Design: A review of published systematic reviews to identify effective non-pharmacological interventions to improve the quality of life of cancer survivors.

Data Sources: Databases searched until May 2017 included PubMed, Cochrane Central, EMBASE, MEDLINE, Web of Science, the Cumulative Index to Nursing and Allied Health Literature, and PsycINFO.

Study Selection: Published systematic reviews of randomised trials of non-pharmacological interventions for people living with and beyond cancer were included; included reviews targeted patients aged over 18. All participants had already received a cancer diagnosis. Interventions located in any healthcare setting, home or online were included. Reviews of alternative therapies or those non-English reports were excluded. Two researchers independently assessed titles, abstracts and the full text of papers, and independently extracted the data.

Outcomes: The primary outcome of interest was any measure of global (overall) quality of life.

Analytical Methods: Quality assessment assessing methdological quality of systematic reviews (AMSTAR) and narrative synthesis, evaluating effectiveness of non-pharmacological interventions and their components.

Results: Of 14 430 unique titles, 21 were included in the review of reviews. There was little overlap in the primary papers across these reviews. Thirteen reviews covered mixed tumour groups, seven focused on breast cancer and one focused on prostate cancer. Face-to-face interventions were often combined with online, telephone and paper-based reading materials. Interventions included physical, psychological or behavioural, multidimensional rehabilitation and online approaches. Yoga specifically, physical exercise more generally, cognitive behavioural therapy (CBT) and mindfulness-based stress reduction (MBSR) programmes showed benefit in terms of quality of life.

Conclusions: Exercise-based interventions were effective in the short (less than 3-8 months) and long term. CBT and MBSR also showed benefits, especially in the short term. The evidence for multidisciplinary, online and educational interventions was equivocal.
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http://dx.doi.org/10.1136/bmjopen-2017-015860DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719270PMC
November 2017

Updated Guidelines for Metastatic Hormone-sensitive Prostate Cancer: Abiraterone Acetate Combined with Castration Is Another Standard.

Eur Urol 2018 Mar 2;73(3):316-321. Epub 2017 Nov 2.

Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK.

Addition of docetaxel to androgen deprivation therapy (ADT) was recommended for patients with newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC), who are fit enough to receive docetaxel. Two recently published trials showed that the addition of abiraterone acetate plus prednisone to ADT has a clear survival benefit and acceptable overall tolerance, and should be considered as another standard of care for newly diagnosed mHSPC.
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http://dx.doi.org/10.1016/j.eururo.2017.09.029DOI Listing
March 2018

Quality of Life Outcomes after Primary Treatment for Clinically Localised Prostate Cancer: A Systematic Review.

Eur Urol 2017 12 27;72(6):869-885. Epub 2017 Jul 27.

Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK. Electronic address:

Context: Current evidence-based management for clinically localised prostate cancer includes active surveillance, surgery, external beam radiotherapy (EBRT) and brachytherapy. The impact of these treatment modalities on quality of life (QoL) is uncertain.

Objective: To systematically review comparative studies investigating disease-specific QoL outcomes as assessed by validated cancer-specific patient-reported outcome measures with at least 1 yr of follow-up after primary treatment for clinically localised prostate cancer.

Evidence Acquisition: MEDLINE, EMBASE, AMED, PsycINFO, and Cochrane Library were searched to identify relevant studies. Studies were critically appraised for the risk of bias. A narrative synthesis was undertaken.

Evidence Synthesis: Of 11486 articles identified, 18 studies were eligible for inclusion, including three randomised controlled trials (RCTs; follow-up range: 60-72 mo) and 15 nonrandomised comparative studies (follow-up range: 12-180 mo) recruiting a total of 13604 patients. Two RCTs recruited small cohorts and only one was judged to have a low risk of bias. The quality of evidence from observational studies was low to moderate. For a follow-up of up to 6 yr, active surveillance was found to have the lowest impact on cancer-specific QoL, surgery had a negative impact on urinary and sexual function when compared with active surveillance and EBRT, and EBRT had a negative impact on bowel function when compared with active surveillance and surgery. Data from one small RCT reported that brachytherapy has a negative impact on urinary function 1 yr post-treatment, but no significant urinary toxicity was reported at 5 yr.

Conclusions: This is the first systematic review comparing the impact of different primary treatments on cancer-specific QoL for men with clinically localised prostate cancer, using validated cancer-specific patient-reported outcome measures only. There is robust evidence that choice of primary treatment for localised prostate cancer has distinct impacts on patients' QoL. This should be discussed in detail with patients during pretreatment counselling.

Patient Summary: Our review of the current evidence suggests that for a period of up to 6 yr after treatment, men with localised prostate cancer who were managed with active surveillance reported high levels of quality of life (QoL). Men treated with surgery reported mainly urinary and sexual problems, while those treated with external beam radiotherapy reported mainly bowel problems. Men eligible for brachytherapy reported urinary problems up to a year after therapy, but then their QoL returned gradually to as it was before treatment.
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http://dx.doi.org/10.1016/j.eururo.2017.06.035DOI Listing
December 2017

Castration-resistant Prostate Cancer: Preservation of Quality of Life and Well-being.

Eur Urol Focus 2016 Dec 14;2(5):472-475. Epub 2016 Sep 14.

Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK. Electronic address:

Managing optimal health in castrate-resistant prostate cancer is a complex clinical challenge. Quality of life should be assessed with disease-specific validated tools and can be used in clinical practice to assist in considering management options.
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http://dx.doi.org/10.1016/j.euf.2016.08.011DOI Listing
December 2016

E-cigarettes and Urologic Health: A Collaborative Review of Toxicology, Epidemiology, and Potential Risks.

Eur Urol 2017 06 7;71(6):915-923. Epub 2017 Jan 7.

Academic Urology Unit, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.

Context: Use of electronic cigarettes (ECs) is on the rise in most high-income countries. Smoking conventional cigarettes is a known risk factor for urologic malignancy incidence, progression, and mortality, as well as for other urologic health indicators. The potential impact of EC use on urologic health is therefore of clinical interest to the urology community.

Objective: To review the available data on current EC use, including potential benefits in urologic patients, potential issues linked to toxicology of EC constituents, and how this might translate into urologic health risks.

Evidence Acquisition: A Medline search was carried out in August 2016 for studies reporting urologic health outcomes and EC use. Snowballing techniques were also used to identify relevant studies from recent systematic reviews. A narrative synthesis of data around EC health outcomes, toxicology, and potential use in smoking cessation and health policy was carried out.

Evidence Synthesis: We found no studies to date that have been specifically designed to prospectively assess urologic health risks, even in an observational setting. Generating such data would be an important contribution to the debate on the role of ECs in public health and clinical practice. There is evidence from a recent Cochrane review of RCTs that ECs can support smoking cessation. There are emerging data indicating that potentially harmful components of ECs such as tobacco-specific nitrosamines, polyaromatic hydrocarbons, and heavy metals could be linked to possible urologic health risks.

Conclusions: ECs might be a useful tool to encourage cessation of conventional cigarette smoking. However, data collection around the specific impact of ECs on urologic health is needed to clarify the possible patient benefits, outcomes, and adverse events.

Patient Summary: While electronic cigarettes might help some people to stop smoking, their overall impact on urologic health is not clear.
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http://dx.doi.org/10.1016/j.eururo.2016.12.022DOI Listing
June 2017

Practical Cooling Strategies During Continuous Exercise in Hot Environments: A Systematic Review and Meta-Analysis.

Sports Med 2017 Mar;47(3):517-532

Faculty of Health and Wellbeing, Sheffield Hallam University, F616 Robert Winston Building, Sheffield, S10 2BP, UK.

Background: Performing exercise in thermally stressful environments impairs exercise capacity and performance. Cooling during exercise has the potential to attenuate detrimental increases in body temperature and improve exercise capacity and performance.

Objective: The objective of this review was to assess the effectiveness of practical cooling strategies applied during continuous exercise in hot environments on body temperature, heart rate, whole body sweat production, rating of perceived exertion (RPE), thermal perception and exercise performance.

Methods: Electronic database searches of MEDLINE, SPORTDiscus, Scopus and Physiotherapy Evidence Database (PEDro) were conducted using medical subject headings, indexing terms and keywords. Studies were eligible if participants were defined as 'healthy', the exercise task was conducted in an environment ≥25 °C, it used a cooling strategy that would be practical for athletes to use during competition, cooling was applied during a self-paced or fixed-intensity trial, participants exercised continuously, and the study was a randomised controlled trial with the comparator either a thermoneutral equivalent or no cooling. Data for experimental and comparator groups were meta-analysed and expressed as a standardised mean difference and 95 % confidence interval.

Results: Fourteen studies including 135 participants met the eligibility criteria. Confidence intervals for meta-analysed data included beneficial and detrimental effects for cooling during exercise on core temperature, mean skin temperature, heart rate and sweat production during fixed-intensity exercise. Cooling benefited RPE and thermal perception during fixed-intensity exercise and improved self-paced exercise performance.

Conclusion: Cooling during fixed-intensity exercise, particularly before a self-paced exercise trial, improves endurance performance in hot environments by benefiting RPE and thermal perception, but does not appear to attenuate increases in body temperature.
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http://dx.doi.org/10.1007/s40279-016-0592-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5309298PMC
March 2017

Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic considerations.

Health Technol Assess 2016 Apr;20(27):vii-xxxvii, 1-367

RAND Europe, Cambridge, UK.

Background: Writing therapy to improve physical or mental health can take many forms. The most researched model of therapeutic writing (TW) is unfacilitated, individual expressive writing (written emotional disclosure). Facilitated writing activities are less widely researched.

Data Sources: Databases, including MEDLINE, EMBASE, PsycINFO, Linguistics and Language Behaviour Abstracts, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature, were searched from inception to March 2013 (updated January 2015).

Review Methods: Four TW practitioners provided expert advice. Study procedures were conducted by one reviewer and checked by a second. Randomised controlled trials (RCTs) and non-randomised comparative studies were included. Quality was appraised using the Cochrane risk-of-bias tool. Unfacilitated and facilitated TW studies were analysed separately under International Classification of Diseases, Tenth Revision chapter headings. Meta-analyses were performed where possible using RevMan version 5.2.6 (RevMan 2012, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Costs were estimated from a UK NHS perspective and three cost-consequence case studies were prepared. Realist synthesis followed Realist and Meta-narrative Evidence Synthesis: Evolving Standards guidelines.

Objectives: To review the clinical effectiveness and cost-effectiveness of TW for people with long-term conditions (LTCs) compared with no writing, or other controls, reporting any relevant clinical outcomes. To conduct a realist synthesis to understand how TW might work, and for whom.

Results: From 14,658 unique citations, 284 full-text papers were reviewed and 64 studies (59 RCTs) were included in the final effectiveness reviews. Five studies examined facilitated TW; these were extremely heterogeneous with unclear or high risk of bias but suggested that facilitated TW interventions may be beneficial in individual LTCs. Unfacilitated expressive writing was examined in 59 studies of variable or unreported quality. Overall, there was very little or no evidence of any benefit reported in the following conditions (number of studies): human immunodeficiency virus (six); breast cancer (eight); gynaecological and genitourinary cancers (five); mental health (five); asthma (four); psoriasis (three); and chronic pain (four). In inflammatory arthropathies (six) there was a reduction in disease severity [n = 191, standardised mean difference (SMD) -0.61, 95% confidence interval (CI) -0.96 to -0.26] in the short term on meta-analysis of four studies. For all other LTCs there were either no data, or sparse data with no or inconsistent, evidence of benefit. Meta-analyses conducted across all of the LTCs provided no evidence that unfacilitated emotional writing had any effect on depression at short- (n = 1563, SMD -0.06, 95% CI -0.29 to 0.17, substantial heterogeneity) or long-term (n = 778, SMD -0.04 95% CI -0.18 to 0.10, little heterogeneity) follow-up, or on anxiety, physiological or biomarker-based outcomes. One study reported costs, no studies reported cost-effectiveness and 12 studies reported resource use; and meta-analysis suggested reduced medication use but no impact on health centre visits. Estimated costs of intervention were low, but there was insufficient evidence to judge cost-effectiveness. Realist synthesis findings suggested that facilitated TW is a complex intervention and group interaction contributes to the perception of benefit. It was unclear from the available data who might benefit most from facilitated TW.

Limitation: Difficulties with developing realist synthesis programme theory meant that mechanisms operating during TW remain obscure.

Conclusions: Overall, there is little evidence to support the therapeutic effectiveness or cost-effectiveness of unfacilitated expressive writing interventions in people with LTCs. Further research focused on facilitated TW in people with LTCs could be informative.

Study Registration: This study is registered as PROSPERO CRD42012003343.

Funding: The National Institute for Health Research Health Technology Assessment programme.
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http://dx.doi.org/10.3310/hta20270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4860558PMC
April 2016

Effects of a lifestyle intervention on endothelial function in men on long-term androgen deprivation therapy for prostate cancer.

Br J Cancer 2016 Feb 14;114(4):401-8. Epub 2016 Jan 14.

Academic Urology Unit, Department of Oncology, Royal Hallamshire Hospital, University of Sheffield, Sheffield S11 7FE, UK.

Background: Treatment of prostate cancer with androgen deprivation therapy (ADT) is associated with metabolic changes that have been linked to an increase in cardiovascular risk.

Methods: This randomised controlled trial investigated the effects of a 12-week lifestyle intervention that included supervised exercise training and dietary advice on markers of cardiovascular risk in 50 men on long-term ADT recruited to an on-going study investigating the effects of such a lifestyle intervention on quality of life. Participants were randomly allocated to receive the intervention or usual care. Cardiovascular outcomes included endothelial function (flow-mediated dilatation (FMD) of the brachial artery), blood pressure, body composition and serum lipids. Additional outcomes included treadmill walk time and exercise and dietary behaviours. Outcomes were assessed before randomisation (baseline), and 6, 12 and 24 weeks after randomisation.

Results: At 12 weeks, the difference in mean relative FMD was 2.2% (95% confidence interval (CI) 0.1-4.3, P=0.04) with an effect size of 0.60 (95% CI <0.01-1.18) favouring the intervention group. Improvements in skeletal muscle mass, treadmill walk time and exercise behaviour also occurred in the intervention group over that duration (P<0.05). At 24 weeks, only the difference in treadmill walk time was maintained.

Conclusions: This study demonstrates that lifestyle changes can improve endothelial function in men on long-term ADT for prostate cancer. The implications for cardiovascular health need further investigation in larger studies over longer duration.
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http://dx.doi.org/10.1038/bjc.2015.479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4815775PMC
February 2016

Exercise for Men with Prostate Cancer: A Systematic Review and Meta-analysis.

Eur Urol 2016 Apr 26;69(4):693-703. Epub 2015 Nov 26.

Department of Oncology, University of Sheffield, Sheffield, UK.

Context: Exercise could be beneficial for prostate cancer survivors. However, no systematic review across cancer stages and treatment types addressing potential benefits and harms exists to date.

Objective: To assess the effects of exercise on cancer-specific quality of life and adverse events in prostate cancer trials.

Evidence Acquisition: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, SPORTDiscus, and PEDro. We also searched grey literature databases, including trial registers. Searches were from database inception to March 2015. Standardised mean differences (SMDs) were calculated for meta-analysis.

Evidence Synthesis: We included 16 randomised controlled trials (RCTs) involving 1574 men with prostate cancer. Follow-up varied from 8 wk to 12 mo. RCTs involved men with stage I-IV cancers. A high risk of bias was frequently due to problematic intervention adherence. Seven trials involving 912 men measured cancer-specific quality of life. Pooling of the data from these seven trials revealed no significant effect on this outcome (SMD 0.13, 95% confidence interval [CI] -0.08 to 0.34, median follow-up 12 wk). Sensitivity analysis of studies that were judged to be of high quality indicated a moderate positive effect estimate (SMD 0.33, 95% CI 0.08-0.58; median follow-up 12 wk). Similar beneficial effects were seen for cancer-specific fatigue, submaximal fitness, and lower body strength. We found no evidence of benefit for disease progression, cardiovascular health, or sexual function. There were no deaths attributable to exercise interventions. Other serious adverse events (eg, myocardial infarction) were equivalent to those seen in controls.

Conclusions: These results support the hypothesis that exercise interventions improve cancer-specific quality of life, cancer-specific fatigue, submaximal fitness, and lower body strength.

Patient Summary: This review shows that exercise/physical activity interventions can improve quality of life, fatigue, fitness, and function for men with prostate cancer.
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http://dx.doi.org/10.1016/j.eururo.2015.10.047DOI Listing
April 2016

Cluster randomised trials with repeated cross sections: alternatives to parallel group designs.

BMJ 2015 Jun 8;350:h2925. Epub 2015 Jun 8.

Health and Wellbeing Research Institute, Sheffield Hallam University, Sheffield, UK.

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http://dx.doi.org/10.1136/bmj.h2925DOI Listing
June 2015

Survivorship and improving quality of life in men with prostate cancer.

Eur Urol 2015 Sep 1;68(3):374-83. Epub 2015 May 1.

Vanderbilt University Department of Urologic Surgery and VA Tennessee Valley Healthcare System, Nashville, TN, USA.

Context: Long-term survival following a diagnosis of cancer is improving in developed nations. However, living longer does not necessarily equate to living well.

Objective: To search systematically and synthesise narratively the evidence from randomised controlled trials (RCTs) of supportive interventions designed to improve prostate cancer (PCa)-specific quality of life (QoL).

Evidence Acquisition: A systematic search of Medline and Embase was carried out from inception to July 2014 to identify interventions targeting PCa QoL outcomes. We did not include nonrandomised studies or trials of mixed cancer groups. In addition to database searches, citations from included papers were hand-searched for any potentially eligible trials.

Evidence Synthesis: A total of 2654 PCa survivors from 20 eligible RCTs were identified from our database searches and reference checks. Disease-specific QoL was assessed most frequently by the Functional Assessment of Cancer Therapy-Prostate questionnaire. Included studies involved men across all stages of disease. Supportive interventions that featured individually tailored approaches and supportive interaction with dedicated staff produced the most convincing evidence of a benefit for PCa-specific QoL. Much of these data come from lifestyle interventions. Our review found little supportive evidence for simple literature provision (either in booklets or via online platforms) or cognitive behavioural approaches.

Conclusions: Physical and psychological health problems can have a serious negative impact on QoL in PCa survivors. Individually tailored supportive interventions such as exercise prescription/referral should be considered by multidisciplinary clinical teams where available. Cost-effectiveness data and an understanding of how to sustain benefits over the long term are important areas for future research.

Patient Summary: This review of supportive interventions for improving quality of life in prostate cancer survivors found that supervised and individually tailored patient-centred interventions such as lifestyle programmes are of benefit.
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http://dx.doi.org/10.1016/j.eururo.2015.04.023DOI Listing
September 2015

Progress toward embracing exercise training as an integral part of prostate cancer treatment.

J Clin Oncol 2014 Aug 7;32(23):2517. Epub 2014 Jul 7.

Royal Hallamshire Hospital, University of Sheffield, Sheffield, United Kingdom.

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http://dx.doi.org/10.1200/JCO.2014.55.1879DOI Listing
August 2014

The dog-leg: an alternative to a cross-over design for pragmatic clinical trials in relatively stable populations.

Int J Epidemiol 2014 Jun 22;43(3):930-6. Epub 2014 Jan 22.

Centre for Primary Care & Public Health, Queen Mary University of London, London, UK.

Background: A cross-over trial design is more powerful than a parallel groups design, but requires that treatment effects do not carry over from one period of the trial to the next. We focus here on interventions in chronic disease populations where the control is routine care: in such cases we cannot assume the intervention effect is easily washed out in crossing over from the experimental intervention back to the control.

Methods: We introduce an alternative trial design for these situations, and investigate its performance. One group is assessed before and after the experimental intervention, whereas two other groups provide respective, independent treatment comparisons in each period. We call this a dog-leg design because of the pattern of assessments in the three groups. The dog-leg design is reminiscent of a stepped wedge design, but with a reduced schedule of assessments and with the notable difference that not all groups receive the intervention.

Results: If the correlation between baseline and follow-up is <0.72, the dog-leg design is more efficient than a parallel groups design with a baseline assessment. The dog-leg design also requires fewer assessments in total than a parallel groups design where participants are only assessed once, at follow-up.

Conclusions: The dog-leg design is simple, and has some attractive properties. Though there is a risk of differential attrition in the three arms, the design's good performance relative to alternatives makes it a useful addition to the methodologist's toolkit.
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http://dx.doi.org/10.1093/ije/dyt281DOI Listing
June 2014

Androgen deprivation therapy and cardiovascular harm: are all men created equal?

Eur Urol 2014 Mar 20;65(3):574-6. Epub 2013 Nov 20.

Division of General Internal Medicine, Brigham and Women's Hospital, and Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1016/j.eururo.2013.11.016DOI Listing
March 2014

Lifestyle changes for improving disease-specific quality of life in sedentary men on long-term androgen-deprivation therapy for advanced prostate cancer: a randomised controlled trial.

Eur Urol 2014 May 4;65(5):865-72. Epub 2013 Oct 4.

Academic Urology Unit, Department of Oncology, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK. Electronic address:

Background: Prostate cancer is a key driver of cancer-related global disability-adjusted life-years. Androgen-deprivation therapy (ADT) for advanced disease is linked to fatigue, reduced physical function, and quality of life (QoL).

Objective: To evaluate the effect of a lifestyle intervention on disease-specific QoL, diastolic blood pressure, and cancer-related fatigue in sedentary men receiving long-term ADT for advanced prostate cancer.

Design, Setting, And Participants: A total of 100 hundred sedentary men with locally advanced or metastatic prostate cancer on long-term ADT were randomised to an intervention or usual care group.

Intervention: A 12-wk lifestyle intervention consisting of aerobic and resistance exercise with parallel dietary advice.

Outcome Measurements And Statistical Analysis: Disease-specific QoL was measured using the Functional Assessment of Cancer Therapy-Prostate (FACT-P) and Functional Assessment of Cancer Therapy-Fatigue (FACT-F) questionnaires at 12 wk postintervention and at 6 mo following withdrawal of support. Analysis of covariance and mixed regression were conducted.

Results And Limitations: Clinically relevant improvements in FACT-P were seen at 12 wk in the intervention group compared with controls (mean difference: 8.9 points; 95% confidence interval [CI], 3.7-14.2; adjusted p=0.001). No difference was apparent at 6 mo (mean difference: 3.3 points; 95% CI, -2.6 to 9.3; adjusted p=0.27). No difference in diastolic blood pressure was seen at either follow-up (all p > 0.05). Clinically relevant improvements in FACT-F were seen at 12 wk (mean difference: 5.3 points; 95% CI, 2.7-7.9; adjusted p<0.001) and maintained following withdrawal of supervision (mean difference: 3.9 points; 95% CI, 1.1-6.8; adjusted p=0.007). Improvements in exercise tolerance and behaviour were maintained at 6 mo (adjusted p<0.001 and 0.038).

Conclusions: A lifestyle intervention resulted in a clinically meaningful improvement in disease-specific QoL that was not maintained postintervention. No effect on blood pressure occurred. Durability of response was seen in fatigue and exercise behaviour. Further evaluation of support structures is essential.

Trial Registration: ISRCTN88605738.
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http://dx.doi.org/10.1016/j.eururo.2013.09.040DOI Listing
May 2014

Primary care delays in diagnosing cancer: what is causing them and what can we do about them?

J R Soc Med 2013 Nov 9;106(11):437-40. Epub 2013 Oct 9.

Primary Care and Public Health Sciences, King's College London, Capital House, London SE1 3QD, UK.

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http://dx.doi.org/10.1177/0141076813504744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3807772PMC
November 2013

Interventions for promoting habitual exercise in people living with and beyond cancer.

Cochrane Database Syst Rev 2013 Sep 24(9):CD010192. Epub 2013 Sep 24.

Queen Mary University of London, Barts & The London School of Medicine and Dentistry, Centre for Primary Care and Public Health, Blizard Institute, Yvonne Carter Building, 58 Turner Street, London, UK, E1 2AB.

Background: The beneficial effects of regular exercise for people living with or beyond cancer are becoming apparent. However, how to promote exercise behaviour in sedentary cancer cohorts is not as well understood. A large majority of people living with or recovering from cancer do not meet exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important.

Objectives: To assess the effects of interventions to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? What adverse effects are attributed to different exercise interventions? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with increased exercise behaviour? What behaviour change techniques are most often associated with increased exercise behaviour?

Search Methods: We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 8, 2012), MEDLINE, EMBASE, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro from inception to August 2012. We also searched the grey literature, wrote to leading experts in the field, wrote to charities and searched reference lists of other recent systematic reviews.

Selection Criteria: We included only randomised controlled trials (RCTs) that compared an exercise intervention with a usual care approach in sedentary people over the age of 18 with a homogenous primary cancer diagnosis.

Data Collection And Analysis: Two review authors working independently (LB and KH) screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that cannot be safely excluded without assessment of the full text (e.g. when no abstract is available). All eligible papers were formally abstracted by at least two members of the review author team working independently (LB and KH) and using the data collection form. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we synthesised studies as a narrative.

Main Results: Fourteen trials were included in this review, involving a total of 648 participants. Only studies involving breast, prostate or colorectal cancer were identified as eligible. Just six trials incorporated a target level of exercise that could meet current recommendations. Only three trials were identified that attempted to objectively validate independent exercise behaviour with accelerometers or heart rate monitoring. Adherence to exercise interventions, which is crucial for understanding treatment dose, is often poorly reported. It is important to note that the fundamental metrics of exercise behaviour (i.e. frequency, intensity and duration, repetitions, sets and intensity of resistance training), although easy to devise and report, are seldom included in published clinical trials.None of the included trials reported that 75% or greater adherence (the stated primary outcome for this review) of the intervention group met current aerobic exercise recommendations at any given follow-up. Just two trials reported six weeks of resistance exercise behaviour that would meet the guideline recommendations. However, three trials reported adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendation of 150 minutes per week. All three incorporated both supervised and independent exercise components as part of the intervention, and none placed restrictions on the control group in terms of exercise behaviour. These three trials shared programme set goals and the following behaviour change techniques: generalisation of a target behaviour; prompting of self-monitoring of behaviour; and prompting of practise. Despite the uncertainty surrounding adherence in many of the included trials, interventions caused improvements in aerobic exercise tolerance at 8 to 12 weeks (from 7 studies, SMD 0.73, 95% confidence interval (CI) 0.51 to 0.95) in intervention participants compared with controls. At six months, aerobic exercise tolerance was also improved (from 5 studies, SMD 0.70, 95% CI 0.45 to 0.94), but it should be noted that four of the five trials used in this analysis had a high risk of bias, hence caution is warranted in interpretation of results. Attrition over the course of these interventions is typically low (median 6%).

Authors' Conclusions: Interventions to promote exercise in cancer survivors who report better levels of adherence share some common behaviour change techniques. These involve setting programme goals, prompting practise and self-monitoring and encouraging participants to attempt to generalise behaviours learned in supervised exercise environments to other, non-supervised contexts. However, expecting most sedentary survivors to achieve current guideline recommendations of at least 150 minutes per week of aerobic exercise is likely to be unrealistic. As with all well-designed exercise programmes in any context, prescriptions should be designed around individual capabilities, and frequency, duration and intensity or sets, repetitions, intensity or resistance training should be generated on this basis.
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http://dx.doi.org/10.1002/14651858.CD010192.pub2DOI Listing
September 2013
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