Changing Practice: Provider-Patient Conversations about Physical Activity

Transcription

1 Changing Practice: Provider-Patient Conversations about Physical Activity An Opportunity for Research Collaboration April 14, 2016 Kirsten A. Nyrop, PhD Research Assistant Professor Div. of Hematology-Oncology

2 Physical Activity after Cancer Diagnosis Health, Eating, Activity and Lifestyle (HEAL) Study: 32% of breast cancer survivors participated in recommended levels of PA (Irwin 2004) American Cancer Society SCS-II: 37% of breast cancer, 43% of prostate cancer, and 35% of colorectal cancer patients meet ACS-recommended levels of physical activity(blanchard, Courneya 2008) Women s Health Initiative Observational Study post-diagnosis PA decreased among 25% of women with breast cancer; unchanged in 35% over 6 years FU (Irwin 2011) Carolina Breast Cancer Study: 35% of study participants met current PA guidelines after breast cancer diagnosis. 59% of participants decreased their activity after diagnosis. African American women were less likely to meet national PA guidelines after diagnosis (Hair 2014) NHANES data: sedentary behavior was 66% in BC survivors and 59% in non-cancer controls (Phillips 2015)

3 Call to Action regarding physical activity in oncology practice NCCN Guidelines for Survivorship: Nutrition and Weight Management, Version (Denlinger 2014) ACS Guidelines for Nutrition and Physical Activity for Cancer Survivors (Rock 2012) American College of Sports Medicine roundtable on exercise guidelines for cancer survivors (Schmitz 2011) Implementing the exercise guidelines for cancer survivors (Wolin 2012) Exercise in clinical cancer care (Santa Mina 2012) The time has come for oncologists to recommend physical activity to cancer survivors (Ruiz-Casado 2014)

4 Practical clinical interventions for diet, physical activity, and weight control in cancer survivors (Demark-Wahnefried Courneya 2015) The oncologist and the oncology care team now stand at a unique interface delivering acute care aimed at a life-threatening disease while at the same time readying the patient for a long and healthy life free of comorbidity. Good nutrition and a physically active lifestyle are central to both pursuits, and it is becoming increasingly apparent that these factors need to be routinely integrated into the delivery of optimal cancer care.

5 Source: Keogh et al. Benefits and barriers of cancer practitioners discussing physical activity with their cancer patients. J Cancer Education (2015)

6 Teachable Moment Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer (Demark-Wahnefried 2005) Lifestyle interventions to reduce cancer risk and improve outcomes (Demark- Wahnefried 2008) focus on family physicians Promoting lifestyle change among cancer survivors: when is the teachable moment? (Rabin 2009) Improving cancer survivorships: targeting PA and inactivity in teachable moments (Chew 2012) Promoting changes in diet and physical activity in breast and colorectal cancer screening settings: an unexplored opportunity for endorsing health behaviors (Anderson 2013) The impact of a cancer diagnosis on the health behaviors of cancer survivors and the family and friends (Humpel 2007) An investigation of the colorectal cancer experience and receptivity to familybased cancer prevention programs (Radecki Breitkpf 2014) Testing the teachable moment premise mixed evidence (Broderick 2014)

7 Human Behavior. Human behavioral change is complex difficult Especially with regard to health behavior (patients) and clinical practice (providers) Exercise interventions are difficult to sustain but is it impossible????

8 3 Questions STAKEHOLDERS 1. What do cancer patients/survivors want (need) to hear or learn from their oncology provider regarding physical activity? 2. What are oncology providers willing (able) to do during a busy clinical visit regarding physical activity interactions? INTERVENTION 3. Based on what is learned from questions 1 and 2, are there scalable and sustainable real world interventions that could be developed and tested collaboratively addressing barriers to (1) provider interactions about PA and (2) patient adherence to provider recommendations?

9 Q1: What do cancer patients/survivors want (need) to hear or learn from their oncology provider regarding physical activity? Extensive research regarding exercise preferences and interest in PA among cancer patients/survivors barriers and facilitators theories of behavioral change in cancer survivors Utility of the Theory of Planned Behavior for understanding exercise during BC treatment (Courneya 1999) Current health behaviors and readiness to pursue life-style changes among men and women diagnosed with early stage prostate and breast carcinomas (Demark-Wahnefried 2000) Exercise counseling and programming preferences of cancer survivors (Jones, Courneya 2002) Older cancer survivors views and preferences for physical activity (Whitehead 2009) Physical activity among cancer survivors: a literature review (Szymiek-Gay 2011) Exercise programming and counseling preferences of breast cancer survivors during or after radiation therapy (Karvinen 2011) Exercise programming preferences and activity levels of cancer patients undergoing radiotherapy treatment (Murnane 2012) African-American BC survivors preferences for various types of physical activity interventions: Sisters Network Inc. web-based survey (Paxton Courneya 2014) Health behavior models and patient preferences regarding nutrition and physical activity after breast and prostate cancer diagnosis (Green 2014) More more more.

10 Q1: What do cancer patients/survivors want (need) to hear or learn from their oncology provider regarding physical activity? But little specific to this question Subjects who received exercise recommendations from their physicians exercised significantly more than subjects who received no communication... A physician's recommendation to exercise appears to be an important factor in a patient's exercise adherence (Segar 1998) most cancer survivors preferred that their oncologist initiate a discussion of exercise. Such a discussion appears to increase survivors exercise levels during treatment. (Jones, Courneya 2002) an oncologist recommendation may increase exercise behavior in newly diagnosed breast cancer survivors, particularly if it is recalled 1 week after the recommendation. (Jones, Courneya 2004) Oncology health care provider advice plus telephone counseling improved physical activity among beast cancer patients and improved patients motivational readiness. (Pinto 2013)

11 Q1: Research Questions Exactly what do cancer patients/survivors want (need) to hear from their oncology provider? key themes, phrases, words that resonate messaging specific to cancer patients/survivors When do they want to hear this message? -- timing along the cancer care continuum How often do they want to hear this message (or various messages)? FOCUS on heterogeneity of patients/survivors: race, ethnicity, gender, cancer stage, cancer site

12 Q2: What are oncology providers willing to do during a busy clinical visit regarding physical activity? physicians recommended exercise to early stage breast (34%) and prostate (36%) cancer survivors (Demark-Wahnefried 2000) A majority of oncologists agreed that exercise was beneficial (62%), important (56%) and safe (63%). Younger, female and medical oncologists generally had more favorable attitudes (Jones, Courneya 2005) Educational strategies aimed at encouraging clinicians [oncologists and surgeons] to promote physical activity in consultations need to be targeted widely amongst the cancer clinician community. (Daley 2008) Medical and radiation oncologists and oncology nurses reasons for recommending PA : (1) helps patients cope, (2) improves their ability to perform daily tasks, (3) attenuates physical declines from treatment, (4) improves mental health, (5) reduces risk of other diseases (Karvinen 2010, 2012)

13 Q2: What are oncology providers willing to do during a busy clinical visit regarding physical activity? Although clinicians recognized the benefits of PA for their patients, few always gave advice about PA. Advice was verbal in nature, very few provided written material, and none referred patients to an exercise specialist (Spellman 2014) PA discussion during most recent medical oncology visit 79% NP, 54% medical oncologist, 64% radiation oncologist, 43% surgeon, 61% PCP (Kenison 2014) patient-provider discussion of physical activity among lung cancer survivors is not optimal. Despite few participants meeting physical activity guidelines, a significant number had neither discussed physical activity with their provider not received a recommendation to increase participation (Philip 2015)

14 Chart Review Aim of the study: Examine the prevalence of oncology provider communications during routine clinic visits. Retrospective chart review (January 2015) Clinician notes and After Visit Summary Key words à physical activity, activity, exercise [Caspersen 1985] Patient sample: clearly appropriate patients Early stage breast, colon and prostate cancer Outpatient visits (new or returning patients) Age 21 or older Nyrop et al. Cancer, January 2016 Exclusion: within 1 week prior or 4 weeks after surgery; surgery-related complications; evidence of metastatic disease; certain comorbidities (recent MI, severe rheumatologic disorder, severe COPD), ECOG >3; evidence of mobility impairment Provider sample: medical oncology, surgical oncology/reconstructive surgery, radiation oncology, urology

15 Results Physician O.R.s PROVIDERS (N=55) % of n=361 encounters % with PA communication Odds Ratio (95% CI) adjusted for clustering by clinician Clinician gender Female Male 67% 33% (p=0.64) 34% 37% (p=0.82) Reference 1.14 (0.36, 3.6) Clinician training MD/DO NP/PA 65% 35% (p=0.57) 34% 37% (p=0.35) Reference 0.60 (0.21, 1.74) Clinician specialty Med Onc Rad Onc Surg Onc Urology 47% 20% 26% 7%) (p<0.0001) 55% 13% 19% 21% (not included in multivariable model because of overlap with treatment variable next slide) Disease site Breast Colon Prostate 75% 9% 17% (p=0.20) 37% 38% 25% Reference 0.38 (0.09,1.67) (p=0.20) 0.17 (0.02,1.32) (p=0.09) 15

16 Results Patient O.R.s PATIENTS (N=302) % of n=363 encounters % with PA communication Odds Ratio (95% CI) adjusted for clustering by clinician Patient gender Female Male 80% 20% (p=0.22) 37% 28% (p=0.65) Referent 1.46 (0.28,7.54) Patient race White African American Other 70% 22% 8% (p=0.21) 35% 40% 21% (p=0.37) Reference 1.31 (0.72,2.39) Patient age group < >80 25% 29% 26% 15% 6% (p<0.001) 23% 34% 40% 45% 50% P= (1.11,1.81) (age as continuous variable) Current treatment Surveillance Surgery Chemotherapy Radiation Endocrine 22% 28% 10% 15% 26% (p<0.0001) 46% 19% 37% 6% 58% 0.96 (0.43,2.13) (p=0.92) 0.20 (0.08,0.5) (p<0.001) 0.52 (0.2, 1.33) (0.17) 0.06 (0.01,0.29) (p<0.001) Reference 16

17 Results Qualitative A. Levels and types of engagement in PA Patient remains active Does not exercise regularly Some nights she walks steps a night (night shift worker) She does water aerobics 3 times/week Golfs in her free time Remains active gardening, mowing lawn, woodworking B. Restrictions on physical activity I discussed with the patient that she may return back to all activities without restrictions You can start more physical activity without restrictions (AVS) Tries to exercise daily but sometimes is not able to do more than walking to the mailbox and back Decreased activity due to cold weather

18 Results Qualitative C. Encouragement or recommendation We discussed importance of physical activity Try something gentle like walking to see if this helps your legs (AVS) I encouraged her to increase her walking level to 30 minutes 5 times a week I provided some information I encouraged exercise including aerobic and weight bearing D. Relationship between PA and weight, nutrition, fatigue Fatigue has been manageable still able to walk a mile She (the patient) noticed that exercise has an effect on her sleep or mood (Regarding depression/anxiety) she is trying to deal with this without using medications, using exercise and getting outside each day

19 Q2: Research Questions Given the well-known barriers to incorporating PA into cancer care What can oncology providers tell us about overcoming their barriers? Is there specific information that is currently missing such as, more definitive evidence regarding prognosis and survival patients other than breast cancer. What is the minimum interaction? PA is safe for you. I recommend you try to exercising regularly?

20 Q3: Are there scalable and sustainable real world interventions regarding provider-patient interactions about PA and patient adherence? Intervention studies The effect of aerobic exercise on self-esteem and depressive and anxiety symptoms among BC survivors (Segar 1998) à à Subjects who received exercise recommendations from their physicians exercised significantly more than subjects who received no recommendation. Effects of an oncologist s recommendation to exercise on self-reported exercise behavior in newly diagnosed BC survivors: single-blind RCT (Jones, Courneya 2004) (Jones, Courneya 2005) à à An oncologist recommendation may increase exercise behavior in newly diagnosed breast cancer survivors, particularly if it is recalled 1 week after the recommendation. The implementation of an oncologist referred exercise self-management program for older BC survivors (Damush 2005)!! An exercise self-management format referred by an oncologist is efficacious for implementing a lifestyle modification change among older breast cancer survivors.

21 Q3: Are there scalable and sustainable real world interventions regarding provider-patient interactions about PA and patient adherence? Intervention studies The effect of oncologists exercise recommendations on the level of exercise and QoL in survivors of breast and colorectal cancer: RCT (Park 2015 S Korea) à Participants who received an oncologist's exercise recommendation with an exercise motivation package significantly increased their level of exercise participation. A randomized trial to promote physical activity among breast cancer patients (Pinto 2013) à à Health care provider advice plus telephone counseling improved PA among breast cancer patients at 3 and 6 months and also differentially improved patients' motivational readiness at all follow-ups, suggesting the potential for exercise promotion in cancer follow-up care.

22 Q 3: Research Questions What do patients want/need and what are oncology clinicians willing/able to provide? Find common ground between the two stakeholder groups What does the implementation literature tell us regarding effective theory-based behavioral change interventions that are scalable and sustainable in real world clinical practice? What is feasible within the U.S. health care system from outpatient clinics of large university-affiliated hospitals to community-based oncology practices How do we translate physical activity research into clinical and community oncology practice? (Courneya 2015 Top 10 research questions related to physical activity and cancer survivorship)

23 Duke - Wake Forest UNC Collaboration All ACC Opportunity!!!