Future Research Directions

Research into exercise motivation and behavior change in cancer survivors is just beginning and we still need answers to many basic questions. In terms of descriptive behavioral epidemiology, we need more studies documenting the exercise patterns and prevalence rates of cancer survivors including the type, frequency, duration, and intensity of the activities. In particular, we need research on resistance exercise which has largely been neglected in public health and exercise oncology circles but is gaining support as a critical component of exercise for health and function, especially for middle-aged and older adults. Moreover, it may be useful to examine the patterns and prevalence rates of fitness parameters (e.g., aerobic capacity, muscular strength, function) as one source of objective information about the exercise behavior of cancer survivors. These research studies would benefit from using prospective designs and objective measures of exercise and/or fitness to improve the quality and validity of the data. The data will need to be collected in all cancer survivor groups including understudied groups (e.g., ovarian, bladder, lung). Data will also be needed for all the various cancer-related time periods (e.g., pretreatment, on various treatments, posttreatment, long term survivors). Ideally, these data will be population-based and should be compared to data from the general population and/or to data from other chronic disease populations (e.g., diabetes, heart disease). When these studies are completed, we will have a better understanding of the natural history of exercise behavior as modified by the cancer experience.

In terms of exercise determinants research, we need a greater appreciation of the factors that influence the various components of exercise behavior (e.g., type, intensity). As one example, we need research on the determinants of walking for exercise because walking is the most popular form of exercise for cancer survivors.17 In terms of the determinants themselves, we need much more research on the broader range of determinants outlined in social ecological frameworks. These determinants may include non-modifiable demographic factors, disease factors (e.g., stage), medical factors (e.g., treatments, side effects), as well as modifiable variables such as elements in the physical and social environments, system factors (e.g., cancer care delivery), personality, and social cognitive variables. In terms of social cognitive variables, there is good evidence that the TPB is a useful framework for understanding exercise in cancer survivors but there are other validated theories that should also be tested (e.g., SCT, the transtheoretical model, self-determination theory). Similar to research on patterns and prevalence rates, we need determinants research that uses prospective designs and objective measures across the entire cancer experience in all cancer survivor groups. When these studies are completed, we will have a better understanding of how the determinants of exercise behavior are modified by the cancer experience.

In terms of exercise behavior change research, which by definition is intervention research, we need to apply rigorous randomized controlled trial methodology. Well-designed and properly executed randomized controlled trials will provide the best evidence ofthe effectiveness ofexercise behavior change interventions in cancer survivors. Some of the key features of this methodology include a defined population, an appropriately powered sample size, proper randomization, blinding of assessors, balanced groups at baseline, an appropriate comparison group, fidelity to the intervention protocols, limited attrition, intention-to-treat analysis, and well-validated outcome measures. If well-conducted, large scale, multicenter trials demonstrate the effectiveness of an exercise behavior change intervention in cancer survivors, then public health organizations, cancer societies, cancer centers, cancer support groups, and cancer care professionals (e.g., oncologists, nurses, physiotherapists, nutritionists, clinical psychologists) will be more likely to adopt and disseminate these interventions.

Importantly, exercise behavior change research in cancer survivors should be informed by the exercise determinants research. Given that exercise determinants research should be guided by theory, this means that exercise behavior change interventions should also be guided by theory. Beyond the utility of a theory for the development of a behavior change intervention, the assessment of a theoretical model during an intervention also allows the determination of why a particular behavior change intervention either worked or did not work for a given cancer survivor group in a given context. This information can then be used in further refinement of the intervention.

Similar to research on the prevalence and determinants of exercise, there will be a strong need to develop behavior change interventions that can motivate and facilitate exercise participation in various cancer survivor groups (e.g., breast, prostate) at all phases of the cancer experience and across clinical settings (e.g., during intensive in-patient and out-patient treatments) and population-based or public health settings (e.g., long term survivors, rural survivors). The nature and content of these behavior change interventions may vary based on all the factors mentioned earlier and should include multilevel interventions that take into account factors unique to the cancer context (e.g., oncologists, cancer centers, cancer societies, cancer support groups, other cancer care professionals). Finally, it will ultimately be very important to conduct research on knowledge translation to determine how best to put these exercise behavior change interventions into practice to help cancer survivors.

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