The benefit of physical activity during and after cancer treatment has been
demonstrated. There is a growing evidence base indicating that structured exercise
interventions delivered before and during cancer treatment (‘prehabilitation’) can have
positive effects on physical and psychological wellbeing before, reduce deterioration
during, and increase rate of recovery following treatment. There is emerging evidence
for exercise prior to and during stem cell transplantation in haemato-oncology patients.
Guidelines recommend prehabilitation and rehabilitation as integral components of the
treatment pathway in multiple myeloma, for whom autologous stem cell
transplantation (ASCT) is a preferred first line treatment. However, provision of
rehabilitation and structured physical activity support is lacking in haemato-oncology
clinical services in the United Kingdom.
This thesis aimed to explore the feasibility of embedding exercise within haematooncology
clinical pathways, with a focus on ASCT in multiple myeloma. It describes multimethods
research that includes: feasibility and outcomes data from a pilot randomised
controlled trial of a prehabilitation and rehabilitation intervention embedded within the
multiple myeloma ASCT pathway; qualitative interview data on the experiences of
myeloma patients who were approached for and declined or took part in exercise
research after referral for ASCT; and data from a national survey of haematology health
professionals on their beliefs and understanding of exercise during haemato-oncology
treatment. Additionally, the impact of the COVID-19 pandemic, the adaptation of the
pilot trial and how this allowed for evaluation of feasibility of both face-to-face and
remotely delivered exercise support will be described.
The pilot trial recruited 50 of 109 (46%) eligible participants with an attrition rate of 34%,
mainly related to failure to undergo ASCT. Loss of follow-up for other reasons was low,
with 33 of 39 (85%) participants who underwent ASCT completing an assessment at final
timepoint. Secondary outcomes indicate benefit of physiotherapist-led exercise prior to,
during and after ASCT with improvements in quality of life, fatigue, functional capacity
and PA evident on admission for ASCT and 3 months post-ASCT.
Eighteen people with myeloma (56% male, mean age 62 years) who declined
participation in the trial and sixteen who took part in the trial were interviewed for the qualitative studies. Themes from analysis of the decliners’ study highlighted that travel
was the most common reason for declining but it was more than a logistical challenge
and that participants welcomed the personalised approach to being asked to participate
in research but their recall of research information was variable. Other important
findings included the impact of reduced physical activity due to treatment, that there is
a lack of support to counteract this and that patients with myeloma may be
underreporting common side-effects of treatment to their clinical teams because these
are expected despite their impact on engagement in daily activities. Themes from
analysis of the pilot trial completers study indicated both altruistic and personal
motivations for participating and remaining in the trial but that allocation to control
group brought about disappointment and may have led to contamination. There were
also disparities in the experience of recovery from ASCT between those who took part
in the intervention and those who did not. Participants also recalled the impact of
diagnosis and early treatment on physical activity and that they saw exercise as
important for preparation and recovery from ASCT.
156 health-professionals completed the survey study. Beliefs of health professionals
regarding the role of physical activity during and after treatment for haematological
cancer were generally positive. A third (31%) reported knowing relevant guidance
related to physical activity for people with cancer and nearly half (47%) reported
providing physical activity advice routinely to their patients. Those reporting familiarity
with guidance were more likely to give advice. However, misalignment existed between
guidelines and advice given by professionals to their patients.
Findings from this thesis suggest that it is feasible to embed a prehabilitation and
rehabilitation intervention into the myeloma ASCT pathway, indicating possible benefit
and that health professionals and patients are accepting and supportive of greater
physical activity support during and after haemato-oncology treatment.