The combination of increasing cancer cases, improved detection and treatment of cancer, and longer survival, means a growing number of people are living beyond a cancer diagnosis. Australia has some of the highest cancer survival rates in the world with a predicted 1 million people having cancer treatment, under medical surveillance or living in the shadow of cancer by 2020. However, many cancer survivors face the challenges of persistent treatment related side effects such as fatigue, as well as an increased risk of cancer recurrence, second primary cancers, functional decline and co-morbid chronic conditions such as cardiovascular disease, diabetes and osteoporosis. There is a strong evidence base supporting the ability of regular physical activity, a healthy diet and weight control to reduce both the short term and longer term effects of cancer treatment and promote and sustain good health1. Likewise there is evidence for the effectiveness of interventions to support survivors to make such lifestyle changes2-6. Despite this, the majority of adult cancer survivors do not meet established guidelines for physical activity, diet and weight control,7-8 and evidence-based lifestyle interventions are not incorporated into routine cancer care so a program has been developed to translate this evidence into practice.
The Healthy Living after Cancer (HLaC) program is a National Health and Medical Research Council (NHMRC) funded Partnership Project between Cancer Council New South Wales, Victoria, South Australia, Western Australia, and the Cancer Prevention Research Centre, School of Public Health, University of Queensland, in collaboration with a large team of Australian and international investigators and is a five year funded research program.
The HLaC program is evaluating the integration of a telephone-delivered lifestyle intervention for cancer survivors into the existing Cancer Council 13 11 20 information and support telephone service offered by Cancer Councils in Australia. The program is available to people treated for any cancer with curative intent who have completed treatment. Program delivery and evaluation began in mid-2015 and will continue until the end of 2018. It is anticipated that approximately 600 participants will complete the program.
Participants receive up to 12 telephone coaching calls over a period of 6 months to assist them to increase physical activity, improve their eating habits, and work towards moderate weight loss if appropriate. The calls are delivered by Cancer Council nurse/health consultant trained in program recruitment, intervention and evaluation protocols.
Coaches have the opportunity to engage with participants and guide them through a structured, client centred lifestyle program. The person centred approach is based on the tenets that: individuals know best about what will work for them in the context of their lives and it’s the participant who chooses to change (or not) and who has to put in the effort. The health coaching approach is grounded in motivational interviewing and makes use of evidence based behaviour change techniques. Key behaviour change skills used by the nurses includes: self-monitoring, goal setting, problem solving, using supports and emphasising the benefits of change and celebrating success.
Nurse/health consultant training was led by the HLaC senior research fellow with involvement from clinical investigators with expertise in behavioural based coaching; exercise interventions and diet/weight loss interventions in cancer; and clinical issues and safety monitoring.
Evaluation consists of a telephone interview, conducted by a research assistant or nurse/health consultant at each Cancer Council, at the beginning and end of the program. Data on program delivery (i.e., number and duration of calls) is collected within the 13 11 20 service database. This data, along with the telephone interview data, will be shared with the lead study agency, the University of Queensland Cancer Prevention Research Centre (CPRC), for program evaluation. A project coordinator and study investigators are available to support Cancer Council staff with program delivery and evaluation activities.
A self-reported survey was designed to explore the coaches’ experience in delivering the Healthy Living after Cancer program. Delivery of health coaching to the cancer survivor is well suited to a specialist cancer nurse in the community setting. Success is dependent upon appropriate training and competence in specific communication skills which differ to those skills required for provision of information and supportive counselling. Nurses welcomed the opportunity to learn new skills such as motivational interviewing. Call recording is conducted as part of the quality assurance of the program and sent to the principal investigator for review. Nurses believed this to be good practice and instrumental in self-reflective practice. The positive nature of the calls offsets the typically more complex and distressing issues affecting those with cancer seeking assistance through the 13 11 20 information and support service, providing balance in the nurses day. Nurses reported enjoying the perceived ability to build capacity of the client to take control and problem solve and found this empowering. Overall, the experience is having a positive impact on nursing practice.
Most nurses did not have any experience in motivational interviewing prior to training received for the HLaC program. Key techniques used by nurses/health consultants are:
- assessing participants’ aims (What outcomes do they want to get out of the program?)
- assessing how important these outcomes are to them (How would their life be different by achieving these aims?)
- assessing their confidence in making behavioural changes to help them achieve their aims
- assessing their readiness to make changes and when needed
- assisting participants to get ‘unstuck’ (make observations that participant isn’t making progress)
- building the discrepancy between their current behaviours and aims, reassessing importance of aims, rolling with resistance and acknowledge participant choice and responsibility
It has been demonstrated that these skills are transferable to other areas of clinical practice and an essential component of person centre care and self-management in chronic disease.
This University of Queensland and Cancer Council collaboration provides an opportunity for national dissemination of an evidence-based intervention to support healthy living among cancer survivors. Rigorous evaluation, including economic analysis, of service-level and client-reported outcomes will provide the practice-based evidence needed to inform subsequent applications for sustained funding.
For further information go to https://www.cancersa.org.au/information/a-z-index/healthy-living-after-cancer
Submitted by: Monica Burns, Cancer Council South Australia
- Kushi LH, Doyle C, McCullough M, et al. American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2012;62(1):30-67.
- Schmitz KH, Holtzman J, Courneya KS, Masse LC, Duval S, Kane R. Controlled physical activity trials n cancer survivors: A systematic review and meta-analysis. iCancer Epidemiol Biomarkers Prev. 2005;14(7): 1588-1595.
- Pierce JP, Natarajan L, Caan BJ, et al. Influence of a diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer: the Women’s Healthy Eating and Living (WHEL) randomized trial. 2007;298(3):289-298.
- Blackburn GL, Wang KA. Dietary fat reduction and breast cancer outcome: Results from the Women’s Intervention Nutrition Study (WINS). Am J Clin Nutr. 2007;86(3):s878-s881.
- Demark-Wahnefried W, Clipp EC, Lipkus IM, et al. Main outcomes of the FRESH START trial: A sequentially tailored, diet and exercise mailed print intervention among breast and prostate cancer survivors. J Clin Oncol. 2007;25(19):2709-2718.
- Morey MC, Snyder DC, Sloane R, et al. Effects of home-based diet and exercise on functional outcomes among older, overweight long-term cancer survivors: RENEW: a randomized controlled trial. 2009;301(18):1883-1891.
- Blanchard CM, Courneya KS, Stein K, American Cancer Society’s SCS-II. Cancer survivors’ adherence to lifestyle behavior recommendations and associations with health-related quality of life: Results from the American Cancer Society’s SCS-II. J Clin Oncol. 2008;26(13):2198-2204.
- Eakin EG, Youlden DR, Baade PD, et al. Health behaviors of cancer survivors: data from an Australian population-based survey. Cancer Causes Control. 2007;18(8):881-894.