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Implementation plans can help integrate exercise into standard care

Note: This post is written by the team of The ONE Group (Oncology – Nutrition – Exercise) at Penn State College of Medicine as part of a first-person blog about their work. Learn more about the group here.

Hello! I’m Dr. Mary Kennedy, a Postdoctoral Research Fellow at Edith Cowan University in Western Australia (WA). My research focuses on implementation in exercise oncology. The aim of my work is to identify how to make exercise a standard part of cancer care.

For the last five years I’ve worked with GenesisCare Australia — a cancer treatment organization — to integrate exercise into standard care across three of their treatment centres in WA. Through this work, I’ve gained insight into why implementing exercise into standard oncology care is so challenging. To make meaningful progress in this space, I think it is important to recognize the following three things:

1. Evidence does NOT equal implementation.
It is a common belief that people will adopt exercise into their practice if they see more evidence that exercise is beneficial. That is not true.

While evidence for the beneficial role of exercise in cancer care is important, it is just the first piece of the implementation puzzle. Once an evidence base is established, dedicated work must be done to understand how to change people’s behaviors and the systems they work in so a new practice can be adopted.

Consider this: Despite the more than 15,000 research studies describing the benefits of exercise for people living with and beyond cancer, a recent ASCO patient survey reported fewer than 15% of people reported receiving a referral to exercise from their oncologist! Evidence of effectiveness alone is not enough to change practice.

2. Knowing WHAT to do is different than understanding HOW to do it.
Effectiveness research tells us what to do (e.g., a 12-week exercise program).

Implementation research helps us understand how to help people (e.g., doctors) and places (e.g., hospitals) adopt evidence-based solutions into practice.

If we want to make exercise standard care in oncology, we need to move beyond a simple call to integrate exercise into care. We need to focus on the “how” questions to help specify exactly who needs to do what in order to achieve integration.

The evolution of GenesisCare’s exercise program in WA outlines the value of asking the “how” questions. At the beginning, the service focused only on “what” to do (e.g., co-locate an exercise clinic within a cancer treatment facility). An evaluation of the clinic’s effectiveness showed positive results. But an implementation evaluation revealed very few people receiving treatment (~12%) were accessing the exercise service.

To better integrate the exercise service into standard care, I worked with GenesisCare to develop an implementation plan that detailed exactly how their employees and organization needed to change in order to integrate exercise into care. For example, their oncologists were directed to provide an exercise referral during an initial patient consult, and the medical record system was re-designed to include exercise appointments.

3. Understand the challenges in YOUR context.
Implementing exercise into care does not have a one-size-fits-all solution. While there are a lot of commonalities, no two settings are the same. Changing practice requires a thorough understanding of the people and places you are trying to change.

Efforts to integrate exercise into care must begin with an exploration of what is (and is not) working in that specific setting. My review of exercise implementation barriers offers a blueprint to guide the process of exploration by outlining the issues most commonly reported across oncology care. Once the specific issues have been identified, an implementation plan that addresses those issues can be created.

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