A hybrid effectiveness-implementation trial of an evidence-based exercise intervention for breast cancer survivors.
BACKGROUND
The primary aims of this hybrid Type 1 effectiveness-implementation trial were to quantitatively assess whether an evidence-based exercise intervention for breast cancer survivors, Strength After Breast Cancer, was safe and effective in a new setting and to qualitatively assess barriers to implementation.


METHODS
A cohort of 84 survivors completed measurements related to limb volume, muscle strength, and body image at baseline, 67 survivors completed measurements 12 months later. Qualitative methods were used to understand barriers to implementation experienced by referring oncology clinicians and physical therapists who delivered the program.


RESULTS
Similar to the efficacy trial, the revised intervention demonstrated safety with regard to lymphedema, and led to improvements in lymphedema symptoms, muscular strength, and body image. Comparison of effects in the effectiveness trial to effects in the efficacy trial revealed larger strength increases in the efficacy trial than in the effectiveness trial (P < .04), but few other differences were found. Qualitative implementation data suggested significant barriers around intervention characteristics, payment, eligibility criteria, the referral process, the need for champions (ie, advocates), and the need to adapt during implementation of the intervention, which should be considered in future dissemination and implementation efforts.


CONCLUSIONS
This trial successfully demonstrated that a physical therapy led strength training program for breast cancer survivors can be implemented in a community setting while retaining the effectiveness and safety of the clinical trial. However, during the translation process, strategies to reduce barriers to implementation are required. This new program can inform larger scale dissemination and implementation efforts.
Department of Psychiatry (RSB), Department of Family Medicine and Community Health (BP, FB, KHS), Abramson Cancer Center (AB, KG, AD, LD, DS, KHS), and Center for Clinical Epidemiology (JCB, KG, AD, LD, DS, KHS), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Good Shepherd Penn Partners, Philadelphia, PA (AB); Biobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, PA (KG).
Rinad S
RS
Beidas
Department of Psychiatry (RSB), Department of Family Medicine and Community Health (BP, FB, KHS), Abramson Cancer Center (AB, KG, AD, LD, DS, KHS), and Center for Clinical Epidemiology (JCB, KG, AD, LD, DS, KHS), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Good Shepherd Penn Partners, Philadelphia, PA (AB); Biobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, PA (KG).
Breah
B
Paciotti
Department of Psychiatry (RSB), Department of Family Medicine and Community Health (BP, FB, KHS), Abramson Cancer Center (AB, KG, AD, LD, DS, KHS), and Center for Clinical Epidemiology (JCB, KG, AD, LD, DS, KHS), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Good Shepherd Penn Partners, Philadelphia, PA (AB); Biobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, PA (KG).
Fran
F
Barg
Department of Psychiatry (RSB), Department of Family Medicine and Community Health (BP, FB, KHS), Abramson Cancer Center (AB, KG, AD, LD, DS, KHS), and Center for Clinical Epidemiology (JCB, KG, AD, LD, DS, KHS), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Good Shepherd Penn Partners, Philadelphia, PA (AB); Biobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, PA (KG).
Andrea R
AR
Branas
Department of Psychiatry (RSB), Department of Family Medicine and Community Health (BP, FB, KHS), Abramson Cancer Center (AB, KG, AD, LD, DS, KHS), and Center for Clinical Epidemiology (JCB, KG, AD, LD, DS, KHS), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Good Shepherd Penn Partners, Philadelphia, PA (AB); Biobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, PA (KG).
Justin C
JC
Brown
Department of Psychiatry (RSB), Department of Family Medicine and Community Health (BP, FB, KHS), Abramson Cancer Center (AB, KG, AD, LD, DS, KHS), and Center for Clinical Epidemiology (JCB, KG, AD, LD, DS, KHS), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Good Shepherd Penn Partners, Philadelphia, PA (AB); Biobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, PA (KG).
Karen
K
Glanz
Department of Psychiatry (RSB), Department of Family Medicine and Community Health (BP, FB, KHS), Abramson Cancer Center (AB, KG, AD, LD, DS, KHS), and Center for Clinical Epidemiology (JCB, KG, AD, LD, DS, KHS), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Good Shepherd Penn Partners, Philadelphia, PA (AB); Biobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, PA (KG).
Angela
A
DeMichele
Department of Psychiatry (RSB), Department of Family Medicine and Community Health (BP, FB, KHS), Abramson Cancer Center (AB, KG, AD, LD, DS, KHS), and Center for Clinical Epidemiology (JCB, KG, AD, LD, DS, KHS), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Good Shepherd Penn Partners, Philadelphia, PA (AB); Biobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, PA (KG).
Laura
L
DiGiovanni
Department of Psychiatry (RSB), Department of Family Medicine and Community Health (BP, FB, KHS), Abramson Cancer Center (AB, KG, AD, LD, DS, KHS), and Center for Clinical Epidemiology (JCB, KG, AD, LD, DS, KHS), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Good Shepherd Penn Partners, Philadelphia, PA (AB); Biobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, PA (KG).
Domenick
D
Salvatore
Department of Psychiatry (RSB), Department of Family Medicine and Community Health (BP, FB, KHS), Abramson Cancer Center (AB, KG, AD, LD, DS, KHS), and Center for Clinical Epidemiology (JCB, KG, AD, LD, DS, KHS), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Good Shepherd Penn Partners, Philadelphia, PA (AB); Biobehavioral Health Science Department, School of Nursing, University of Pennsylvania, Philadelphia, PA (KG). Schmitz@upenn.edu.
Kathryn H
KH
Schmitz
D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D001828:Body Image; D001943:Breast Neoplasms / Q000503:physiopathology / Q000523:psychology / Q000534:rehabilitation*; D019317:Evidence-Based Medicine; D015444:Exercise / Q000502:physiology / Q000523:psychology; D005260:Female; D006801:Humans; D055048:Integrative Medicine / Q000191:economics / Q000458:organization & administration*; D008209:Lymphedema / Q000628:therapy*; D008875:Middle Aged; D053580:Muscle Strength; D018482:Muscle, Skeletal / Q000502:physiology; D018579:Patient Selection; D016730:Program Development; D015397:Program Evaluation; D012017:Referral and Consultation; D055070:Resistance Training / Q000009:adverse effects / Q000191:economics / Q000458:organization & administration; D017741:Survivors / Q000523:psychology*