Personalised Exercise Rehabilitation in Cancer Survivorship: The PERCS Triage and Referral System Study Protocol

Personalised Exercise Rehabilitation in Cancer Survivorship: The PERCS Triage and Referral System Study Protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Personalised Exercise Rehabilitation in Cancer Survivorship: The PERCS Triage and Referral System Study Protocol Louise Brennan, Grainne Sheill, Sonya Collier, Peter Browne, Claire L. Donohoe, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3178374/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Apr, 2024 Read the published version in BMC Cancer → Version 1 posted 9 You are reading this latest preprint version Abstract Background: To effectively embed exercise rehabilitation in cancer survivorship care, a co-ordinated system of acute and community exercise rehabilitation services, forming a stepped model of care, is recommended. Patients can be directed to the exercise rehabilitation service which best meets their needs through a system of assessment, triage and referral. Triage and referral systems are not yet widely applied in cancer survivorship practice and need to be evaluated in real-world contexts. The PERCS (Personalised Exercise Rehabilitation in Cancer Survivorship) study aims to evaluate the real-world application of an exercise rehabilitation triage and referral system in cancer survivors treated during the COVID-19 pandemic. Secondary aims are to evaluate change in physical and psychosocial outcomes, and to qualitatively evaluate the impact of the system and patient experiences, at three months after application of the triage and referral system. Methods: This study will assess the implementation of an exercise rehabilitation triage and referral system within the context of a physiotherapy-led cancer rehabilitation clinic for cancer survivors who received cancer treatment during the COVID-19 pandemic. The PERCS triage and referral system supports decision making in exercise rehabilitation referral by recommending one of three pathways: independent physical activity; fitness professional referral; or health professional referral. Up to 100 adult cancer survivors treated during the COVID-19 pandemic who have completed treatment and have no signs of active disease will be recruited. We will assess participants’ physical and psychosocial wellbeing and evaluate whether medical clearance for exercise is needed. Participants will then be triaged to a referral pathway and an exercise recommendation will be collaboratively decided. Reassessment will be after 12 weeks. Primary outcomes are implementation-related, guided by the RE-AIM framework. Secondary outcomes include physical function, psychosocial wellbeing and physical activity levels. Qualitative analysis of semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) will provide insights on implementation and system impact. Discussion: The PERCS study will investigate the real-world application of a cancer rehabilitation triage and referral system. This will provide proof of concept evidence for this triage approach and important insights on the implementation of a triage system in a specialist cancer centre. Trial Registration: This study is registered on ClinicalTrials.gov, registration number: NCT05615285, date registered: 14/11/2022. cancer survivorship rehabilitation exercise triage implementation function psychosocial COVID-19 physiotherapy Figures Figure 1 Figure 2 Background The immediate and long-term sequelae of cancer treatment, including cardiopulmonary deconditioning, impaired bone health, altered body composition, and increased rates of fatigue, depression and anxiety is well-documented [ 1 , 2 ]. Compelling evidence from randomised clinical trials shows aerobic and resistance exercise training can have positive impact across numerous physical and psychosocial outcomes including anxiety, depression, cancer-related fatigue, health-related quality of life (QOL) and self-reported physical functioning [ 3 ]. This evidence was synthesised in the 2019 American College of Sports Medicine (ACSM) Exercise Guidelines for Cancer Survivors, which presented the minimal recommended levels of physical activity for cancer survivors as: 30 minutes of moderate intensity aerobic exercise three times per week and twice-weekly resistance training [ 3 ]. These guidelines support exercise prescription for all people living with and after cancer. Internationally, expert groups have called for better integration of exercise rehabilitation into cancer care pathways [ 4 , 5 ]. To effectively translate the ACSM Exercise Guidelines research into practice, the development of a collaborative, coordinated system between hospital-based and community-based programmes, with established referral pathways enabling access to rehabilitative care from diagnosis to the post-treatment period is recommended. This should be underpinned by a stepped model of care that directs patients to the right level of service to meet their individual needs [ 6 ]. Currently, this model of care remains aspirational in most healthcare systems [ 6 ]. Research by our group finds that, in Ireland, people with and after cancer frequently do not receive support to enable them to become more physically active due to under-resourced and disjointed acute and community services, and a lack of information and awareness by both patients and the oncology multi-disciplinary team [ 7 ]. People living with and after cancer need a range of exercise rehabilitation services, and the level of professional support or supervision required depends on factors such as level of impairment, co-morbidities, and exercise-related self-efficacy. Within a stepped model of care, exercise rehabilitation can be categorised into different ‘levels’, which are typically classified as i) unsupervised, unspecialised exercise rehabilitation; ii). supervised, community-based exercise rehabilitation, broadly specialised to those with a history of cancer or chronic disease; iii). highly specialised exercise rehabilitation, supervised by a specialist healthcare professional [ 8 , 9 ]. A screening approach which triages people according to their level of need and directly refers to the most suitable exercise rehabilitation service can contribute to a patient-centred, efficient pathway of care, and can prioritise specialist services for those who most need them [ 10 ]. There are exciting ongoing efforts internationally to develop stepped-care models and triage and referral systems for exercise rehabilitation in cancer survivorship. The Cancer Rehabilitation to Recreation (CaReR) Framework [ 11 ] aims to increase physical activity after cancer through a three-phase framework spanning Rehabilitation, Fitness and Recreation. The framework does not include a triage system to support decision making in identifying which phase of the framework best meets a patient’s needs. The theoretical model, which is proposed as an amalgamation of the Stepped Care Framework and the Transformative Exercise Framework [ 8 , 11 , 12 ], incorporates different levels of clinical oversight, from fitness professional to physiotherapist, along a spectrum of physical activity counselling across hospital and community settings. Fitness professionals can play an important and impactful role in exercise rehabilitation of cancer survivors with lower levels of impairment, by delivering exercise programmes which are generally community-based and more accessible and affordable than programmes in healthcare settings [ 5 ]. Physiotherapy-delivered programmes are most suitable for patients with cancer-related comorbidities or physical impairments [ 5 ]. Physiotherapists are core members of the oncology multi-disciplinary team who specialise in rehabilitation and exercise prescription, [ 7 ] and can assess and manage many of the common physical side effects of cancer treatment such as weakness, cachexia, fatigue, loss of balance, lymphoedema and pain [ 16 ]. In a recent qualitative analysis of semi-structured interviews with oncology-specialist physiotherapists in Ireland, physiotherapists called for all cancer survivors to have access to a physiotherapy assessment and for greater emphasis on improving QOL within cancer care but reported a lack of funding and resources to address patient needs [ 7 ]. The Exercise in Cancer Evaluation and Decision Support (EXCEEDS) triage model is a two-part decision support tool designed to be used at the point of care by multi-disciplinary users. EXCEEDS evaluates cancer survivors’ physical activity levels and chronic disease risks and recommends an appropriate level of exercise service: cancer rehabilitation, clinically supervised exercise, supervised community-based cancer specific exercise or unsupervised, generic community-based exercise [ 9 ]. The EXCEEDS algorithm has not yet been evaluated in practice and the triage outcomes may be difficult to implement in Ireland, where there is limited provision of supervised exercise programmes for cancer survivors in community- and healthcare-based settings (both public and private) [ 17 ]. This situation is not dissimilar to the situation in many countries where exercise rehabilitation services for cancer survivors are only starting to develop [ 18 , 19 ]. There is a need for an exercise rehabilitation triage and referral system which will work in a country with limited cancer rehabilitation resources [ 7 ]. To be effectively implemented, triage and referral systems should be easily and rapidly applicable in practice, should be adaptable to different clinical contexts, and should optimally utilise the services available in the local healthcare setting [ 13 , 14 ]. In line with the best available evidence in exercise oncology, such a system should be based on the 2019 ACSM guidelines for exercise in patients in cancer, and should consider patients’ current levels of physical activity (both pre- and post-cancer treatment) while also being sensitive to identify possible individual risks of increasing physical activity [ 15 ]. In June 2021, the Irish Cancer Society, in partnership with the National Cancer Control Programme in Ireland, launched the COVID-Cancer Rapid Response Award. The aim was to identify evidence-based mitigations for the burdens brought about by the COVID-19 pandemic on people living with or beyond cancer in Ireland. The pandemic had profound physical and psychosocial effects on the general population and there are major concerns that cancer survivors may be disproportionally impacted [ 20 ]. Internationally, there was a high prevalence of psychological strain, stress and isolation among cancer survivors during this period [ 21 ]. In Northern Ireland, 61% of previously active cancer survivors, reported a psychosocial impact of the COVID-19 restrictions including loneliness, lack of social support, decreased motivation to exercise, fear, anxiety and depression, while 32% reported a physical impact including deterioration in health and fitness, increased pain and body weight, and changes in dietary habits habits[ 22 ]. Alongside the existing need to make evidence-based exercise rehabilitation a priority for cancer care, there is now an additional, urgent need to mitigate the dual impact of cancer treatment and COVID-19 on physical and psychosocial health. The Personalised Exercise Rehabilitation in Cancer Survivorship (PERCS) study, which is funded through the COVID-Cancer Rapid Response Award, will test the real-world application of an exercise rehabilitation triage and referral system within a physiotherapy-led cancer rehabilitation clinic. The system aims to improve physical activity levels in participants by optimally utilising existing exercise rehabilitation services, particularly those in the community, while reserving specialist exercise rehabilitation services delivered by physiotherapists for patients who require a more specialised level of care. The triage and referral system will be applied with people who received cancer treatment during the height of the COVID-19 pandemic, with a view to providing additional supports to this group who experienced exceptional challenges during their treatment. Methods Study aims The overall aim of this study is to evaluate the real-world application of an exercise rehabilitation triage and referral system on physical and psychosocial outcomes in cancer survivors treated during the COVID-19 pandemic. The triage and referral system will be delivered within the context of a physiotherapy-led cancer rehabilitation clinic in a specialist national cancer centre. The study objectives are to: Apply an exercise rehabilitation triage and referral system for cancer survivors in a single specialist cancer centre Describe the real-world implementation of the triage and referral system Evaluate change in real-world physical functioning outcomes and psychosocial outcomes after 12 weeks following application of the triage and referral system Qualitatively evaluate impact on health-related QOL, patient experience and psychosocial outcomes after 12 weeks following application of the triage and referral system Study design This study will use a pre-post-test design to examine the real-world application of an exercise rehabilitation triage and referral system for cancer survivors. The exercise rehabilitation triage and referral system will be applied following a baseline assessment (T0) and will guide patient referral to one of three exercise rehabilitation pathways (Figure 1). A follow-up assessment will be completed after 12-weeks (T1). The study will take place in the Wellcome-Health Research Board (HRB) Clinical Research Facility (CRF) at St James’s Hospital, Dublin. Ethical approval has been obtained from the Tallaght University Hospital/ St James’s Hospital Joint Research Ethics Committee (Study ID 0670) and hospital approval to conduct research from the Research and Innovation Office at St James’s Hospital. Any amendment to the protocol which may impact on the conduct of the study will be submitted as an amendment for approval to the ethics committee. PERCS study was registered with ClinicalTrials.gov on 14/11/2022, trial identifier NCT05615285 and will be performed according to the Declaration of Helsinki. Study participants PERCS will recruit up to 100 patients who have been diagnosed with cancer at St James’s Hospital between March 2020 and March 2022. St James’s Hospital is the largest cancer centre in Ireland with high-volume national, supra-regional and regional teams and structures for multiple malignancies and dedicated cancer prehabilitation and rehabilitation pathways managed by a team of clinical specialist physiotherapists. Participants must meet the following eligibility criteria: have completed adjuvant chemotherapy and/or radiotherapy; be at least 6 weeks post-surgery; do not show signs of recurrent or metastatic disease at the time of enrolment; be over the age of 18 years; be able to provide written informed consent. Clearance to participate in exercise, as determined by the ACSM preparticipation health screening recommendations, will be a pre-requisite for undergoing the exercise rehabilitation triage and referral system [15]. Clearance from a general practitioner or consultant to participate in the study will be required if initial assessment or study pre-screening identifies any of the following conditions: known and symptomatic cardiovascular, metabolic, or renal disease; signs or symptoms suggestive of cardiovascular, metabolic, or renal disease; and recognised precautions for exercise [15, 23]. Screening and Recruitment Potential participants will be identified by the clinical cancer prehabilitation and rehabilitation physiotherapy team from a database of patients who were referred to the OpFit Cancer Prehabilitation programme at St James’s Hospital, beginning from March 2020. Further eligibility screening will be completed by the research team. Potential participants will be sent a letter of invitation to participate, which will include a participant information leaflet (PIL) and a cover letter including contact details for the study team. One week after the anticipated arrival date of this letter, a member of the research team will follow up with a phone call to answer any questions, to confirm if the person is or is not interested in participating in the study, and, where applicable, obtain verbal consent to participate and schedule an initial assessment. Full written consent in duplicate will be obtained at the T0 assessment, after which an entry will be made on the participant’s electronic patient record that they are participating in the study and their General Practitioner will be informed by letter. Individuals who decline participation will have the opportunity to consent to providing information on their demographics, physical activity levels, reasons for declining, and equality, diversity and inclusion metrics to help the research team understand the population who did not participate. A separate written informed consent form will be completed for this data collection. PERCS Exercise Rehabilitation Triage and Referral System The PERCS exercise rehabilitation triage and referral system was developed by the PERCS research team and an overview is presented in Figure 2. The system involves: Gathering specific information through patient assessment Completing triage questions to inform a decision on the best level of exercise rehabilitation for a patient A discussion of triage outcome with the patient, collaborative creation of a physical activity plan, and making any required referrals to exercise rehabilitation services. To complete the PERCS exercise rehabilitation triage and referral system, an assessment must be conducted to gather, at a minimum, the following information: past medical history, physical activity levels, Timed Up & Go (TUG) and Eastern Cooperative Oncology Group Performance-Status (ECOG-PS). Two triage questions use assessment information to guide the user to one of three recommended pathways (‘triage levels’) for exercise rehabilitation advice and onward referral (Figure 2) [3, 5]. The assessor will inform participants of their triage level, and a plan for physical activity over the coming 12 weeks will be developed in collaboration with the participant, including making a referral as needed. In this study, the triage system will be completed again at T1 to assess for (i) triage level recategorisation and (ii) change in individual component items. Onward referral will not be performed at T1. Triage question 1: Physical activity assessment Question 1 identifies whether patients do or do not require additional support to become more physically active by asking if they are currently meeting the recommended levels pf physical activity according to the ACSM Consensus Statement for Exercise Prescription in Cancer Survivors [3]. The PERCS triage and referral system considers participants who are physically active at a moderate aerobic intensity for 30 minutes, 3 times per week as adherent to physical activity guidelines for aerobic exercise, and those completing at least twice weekly resistance exercise for 30 minutes as adherent to physical activity guidelines for resistance training. To evaluate current adherence to physical activity guidelines, two questions will be asked, as recommended by Schmitz et al. (2019) [5]: How many days during the past week have you performed physical activity where your heart beats faster and your breathing is harder than normal for 30 minutes or more? How many days during the past week have you performed physical activity to increase muscle strength, such as lifting weights? Triage Question 2: Assess level of supervision needed Question 2 seeks to identify if patients require support to become more active from a healthcare professional or from a fitness professional. Participants at heightened risk for adverse events associated with increasing current physical activity levels are identified by evaluation using the triage approach adapted by Campbell et al. from the National Comprehensive Cancer Network (NCCN) Survivorship Guidelines (Table 1) [3, 24], the TUG [25] and the ECOG-PS assessment of a patient’s level of functioning [26]. Increased risk of adverse events as identified by any one of these three outcomes will lead the assessor to make a referral to a health professional for a specialist level of support in becoming more physically active. Table 1 Adapted National Comprehensive Cancer Network triage approach based on risk of exercise-induced adverse events[3, 24] Description of Patients Evaluation, prescription, and programming recommendations No comorbidities No further pre-exercise medical evaluation. Follow general exercise recommendations Peripheral neuropathy, arthritis/musculoskeletal issues, poor bone health (e.g., osteopenia or osteoporosis), lymphoedema Pre-exercise medical evaluation recommended. Modify general exercise recommendations based on assessments. Consider referral to trained personnel. Lung or abdominal surgery, ostomy, cardiopulmonary disease, ataxia, extreme fatigue, severe nutritional deficiencies, worsening/changing physical condition (e.g., lymphoedema exacerbation), bone metastases Pre-exercise medical evaluation and clearance by a physician before commencing exercise. Referral to trained personnel. Co-morbidity Status Co-morbidity status will be evaluated using NCCN triage approach based on risk of exercise-induced adverse events contained within their Survivorship Guidelines [24]. Disease-specific and treatment related side-effects which are considered to increase risk of exercise-induced adverse events will be identified in assessment using a standardised case report form. Falls Risk The Timed Up and Go test is a reliable measure of functional mobility, balance and falls risk. It records the time in seconds it takes for a participant to stands up from a chair, walk 3m, turn back and sit in the chair. A faster time indicates better functional mobility, and a cut-off of 13.5 seconds is indicative of older adults at heightened falls risk [27]. Eastern Cooperative Oncology Group-Performance Status The ECOG-PS is a method of assessing the functional status of a patient that is widely used in oncology, particularly clinical trials, to define the population of patients to be studied in a trial, and track change in a patient’s level of functioning due to treatment during a trial (Table 2). Table 2 Eastern Cooperative Oncology Group- Performance Status (ECOG-PS) Grade ECOG-PS 0 Fully active, able to carry on all pre-disease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work 2 Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours 3 Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours 4 Completely disabled; cannot carry on any selfcare; totally confined to bed or chair 5 Dead Triage and Referral System Outcomes The outcome of the Triage and Referral system is discussed by the physiotherapist and participant at the end of the assessment appointment. The triage and referral system leads to three possible outcomes: Triage Level 1: Participants who are currently meeting recommend levels of physical activity will be advised by the physiotherapist to continue with their current physical activity. Participants who want to increase their physical activity to achieve a particular goal will receive advice but will not be referred to a service. Triage Level 2: Participants who are not currently exercising to recommended levels and do not require medical supervision to exercise will be referred to a ‘local exercise service’, which is led by an exercise or fitness professional who is not a healthcare professional. Examples of local exercise services run by fitness professionals are: exercise programmes which are run specifically for cancer survivors, chronic disease populations or older adults; online exercise classes for chronic disease populations; a suitable local fitness class; or an exercise service provided by a community cancer support centre (charity-based). The choice of programme will be decided in collaboration with the participant, taking into account their preference for exercise modality, service location, and other accessibility factors such as time, duration, and frequency. The PERCS physiotherapist will provide contact details of the selected programme, will make a referral where needed and will encourage self-referral where possible. To aid communication with fitness professionals, a standardised information sheet will be provided to participants outlining the results of the PERCS assessment, stating low risk of adverse events with exercise, and providing contact details for the PERCS physiotherapist. Triage Level 3: Participants who are not currently exercising to recommended levels and who are deemed to require medical supervision to exercise, will be referred via the electronic patient record system to the Clinical Specialist Physiotherapist in Cancer Rehabilitation at St James’s Hospital (co-author GS) who will manage the referral through her clinical pathway. This may involve online or face-to-face assessment, online or face-to-face treatment sessions/exercise class sessions, discussion with the multidisciplinary team or onward referral to primary care physiotherapy services. The interventions provided by the Clinical Specialist Physiotherapist in Cancer Rehabilitation will be individualised to each participant based on clinical judgement and assessment. All participants will be advised to visit the PERCS website (www.cancerrehabilitation.ie), which was co-designed with patient representatives at the start of the PERCS study. The aim of the website is to be a national online resource for information on physical activity and cancer. The website contains concise, reliable information from trusted sources, aerobic and resistance training videos, and a national directory of exercise rehabilitation services which are suitable for people living with and after cancer. All participants will receive a follow-up telephone call one week post T0 assessment to answer any questions and support engagement in the recommended pathway. Further phone calls will be scheduled if required to support the participant with their referral pathway, e.g. to ensure referrals were received. Context of Implementation For the purposes of this real-world implementation study, the exercise rehabilitation triage and referral system will be applied within the context of a physiotherapist-led ‘Cancer Rehabilitation Clinic’. In this context, the physiotherapist will apply a biopsychosocial approach to assessments, identifying holistic needs of participants, setting appropriate patient-centred goals and developing local referral pathways internally and externally to support a diverse range of rehabilitation needs. Measures Primary Outcomes: Real-world implementation PERCS primary outcomes relate to evaluating the real-world application of the Triage and Referral System, namely, an implementation analysis using RE-AIM planning and evaluation framework (Table 3) [28]. The RE-AIM framework consists of five dimensions: Reach, Effectiveness, Adoption, Implementation and Maintenance, which help to plan programmes with greater external validity, improve the chances of a programme working in a real-world setting and identify the relative strengths and weakness of an approach. Three dimensions of RE-AIM will be applied to this project: Reach, Effectiveness and Implementation. In this feasibility study, adoption or maintenance of the system will not be assessed. Table 3 Implementation outcomes for PERCS study Implementation construct Implementation outcome RE-AIM dimension Rate of eligibility for recruitment Percentage of patients on prehabilitation list who are eligible Percentage of referrals to the study from clinical team who are eligible Reasons for ineligibility Reach Enrolment rate Percentage of people enrolled in study from those who were approached for recruitment. Reasons for declining participation Reach Participant characteristics Socio-demographics, medical history and cancer history, inclusion, equality and diversity characteristics of participants. Compare to non-participant data, where possible Reach Assessment attendance rates Percentage of participants attending scheduled assessments at T0 and T1 Reason for non-attendance Reach, Implementation Attrition rates Percentage of participants who did or did not proceed to attend the service they were referred to Percentage of participants who attended T0 assessment that attend T1 assessment Reasons for non-attendance Reach, Implementation Engagement with referral Level 1 participants: percentage meeting recommended physical activity levels at T1 Level 2 participants: percentage attending local exercise programme at the agreed level of attendance; percentage meeting recommended levels of physical activity at T1 Level 3 participants: proportion of physiotherapy sessions attended per participant; percentage meeting recommended levels of activity at T1 Percentage meeting recommended levels of activity on weekly basis, as per weekly diary Change in activity levels from T0 – T1 Effectiveness, Implementation Referral outcomes Time from assessment to referral being sent Percentage of referrals accepted at initial site Time from referral sent to initial appointment Implementation Triage Percentage of people triaged to each level Percentage triaged to another level after initial triage and why Implementation Safety Number and nature of adverse events occurring in assessment process Implementation Qualitative feasibility Feasibility data gathered from semi-structured interviews with participants Reach, Effectiveness, Implementation RE-AIM: Reach, Effectiveness, Adoption, Implementation, Maintenance Socio-demographic Data and Medical History At T0, patient demographics, medical history including cancer history and socio-economic data including equality, diversity, and inclusion (EDI) data will be collected using a standardised case report form. EDI data will be collected to meet American Society of Clinical Oncology guidance that research stakeholders should collect and publish aggregate data on diversity of trial participants [29]. The EDI data collection template was developed in line with European Union Equality data collection guidelines [30], in consultation with an external academic EDI specialist. Secondary Outcomes The assessment battery is presented in Table 4. Assessments will be performed at baseline (T0) and after 12-weeks (T1). The battery consists of secondary outcomes and two additional (ECOG-PS and TUG) which are used to complete the triage and referral system. Table 4. Secondary outcomes of implementation study Outcome Measures T0 T1 Assessment of Physical Functioning Physical activity levels International Physical Activity Questionnaire X X Exercise diaries X Health Behaviour and Stages of Change Questionnaire Assessment questions [5]* X X X X Self-Efficacy for Exercise Self-Efficacy for Exercise Scale X X Self-reported function Patient-specific functional scale X X Muscle strength Hand Grip Strength X X Functional lower body strength 30-second Sit-to-Stand X X Aerobic Capacity and Endurance Six Minute Walk Test X X Anthropometrics Height X X Weight Body Mass Index X X X X Nutritional risk screening Mini Nutritional Assessment X X Assessment of Psychosocial Concerns X X Quality of Life European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire X X Fatigue Multidimensional Fatigue Inventory X X Anxiety and depression Hospital Anxiety and Depression Scale X X Triage assessment Physical activity levels Comorbidity status Falls risk Functional status Assessment questions [5]* National Comprehensive Cancer Network triage approach Timed-Up and Go Eastern Cooperative Oncology Group- Performance Status X X X X X X X X Other Qualitative assessment Semi–structured interviews (focus groups or 1:1) X Engagement with referral Exercise diary; T1 assessment X *Subjective questions regarding physical activity levels are used both as a secondary outcome, and to inform the triage and referral system Physical Activity and Motivation to Exercise Physical activity at T0 and T1 will be assessed using the self-administered International Physical Activity Questionnaire (IPAQ) [31]. The IPAQ (short-form) consists of 7 questions capturing activity levels during the previous 7 days. Data is processed using a standardised scoring protocol. Readiness to change will be assessed at T0 using the Health Behaviour and States of Change Questionnaire, which is underpinned by the Transtheoretical model [32] enabling categorisation of patients into precontemplation, contemplation and actions stages of change. Self-efficacy for exercise, i.e. the extent to which a person believes in their ability to execute an exercise plan [33], will be measured using the Self-Efficacy for Exercise Scale [33, 34]. This self-report scale consists of 9 statements describing adverse circumstances for exercise (e.g. 'The weather was bothering you’) against which the user must rank their level of confidence from 0-10 that they would exercise three times per week for 20 minutes under that circumstance. Levels of physical activity will also be captured through asking the two physical activity questions, described above, and through completion of a weekly exercise diary which is tailored for each triage level. Participants assigned to Level 1 will record their weekly aerobic and strength exercise participation. Participants assigned to Level 2 will record their weekly attendance at their local exercise facility and any additional exercise completed. Participants assigned to Level 3 will record physiotherapy sessions attended and the physical activity recommendations given by their physiotherapist. The weekly diary also contains contact details for the PERCS research team, information on exercise after cancer treatment and practical and safety advice for those aiming to increase their activity levels. Adherence will also be explored in semi-structured interviews and through discussion with participants at T1 assessment. Hand Grip Strength and Functional Lower Body Strength Hand grip strength, which provides a measure of hand and forearm strength and correlates well with overall muscle strength and physical function [35], will be measured by calibrated handheld dynamometry from a standard seated position with elbows at 90 degrees. Measurements will be taken in triplicate and the highest value recorded for data entry. Leg strength and endurance will be measured using the 30-second sit to stand test. The number of stands a person can complete from a standardised-height chair in 30 seconds without using arms for assistance will be recorded. Self-reported Function The patient-specific functional score is a self-report outcome measure of function[36]. Participants will identify up to three important activities which they are having difficulties performing, and then rate their current ability to do each activity from 0 (unable to perform) to 10 (able to perform at the same level as before illness). Anthropometric Measures Weight (kilogrammes (kg)) and height (centimetres (cm)) will be recorded by standard methods using a calibrated scales and stadiometer. Body mass index (BMI) will be calculated as weight (kg)/ height (metres (m 2 )). Aerobic Capacity and Endurance Aerobic capacity and endurance will be measured using the six-minute walk test, administered according to the American Thoracic Society Guidelines [37]. Participants will walk for 6 minutes along a 30m walkway in a hospital corridor with the aim of achieving the furthest distance possible. Nutritional Risk Screening The Mini-Nutritional Assessment (MNA) is a validated nutritional screening and assessment tool that can identify malnutrition and risk of malnutrition in older populations. The MNA consists of 6 questions which can be summed to distinguish between elderly patients with: 1) adequate nutritional status, MNA > or = 24; 2) protein-calorie malnutrition, MNA < 17; 3) at risk of malnutrition, MNA between 17 and 23.5. Assessment of Psychosocial Concerns: Quality of life Health-related QOL will be measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC- QLQ-C30)[38]. QOL categories include functional scales (physical, role, cognitive, emotional, social), symptom scales (fatigue, pain, and nausea and vomiting), global health status and QOL scale, in addition to several single-item symptom measures. Fatigue Fatigue will be measured using the Multidimensional Fatigue Inventory (MFI-20), a 20-item scale that measures the impact of fatigue in five dimensions: general, physical, cognitive, motivation and usual activities. It is scored from 1-20, with a cut-off score of ≥13 indicating severe fatigue[39]. Anxiety and Depression Anxiety and depression will be measured using the Hospital Anxiety and Depression Scale (HADS), a self-administered questionnaire and reliable instrument for detecting states of anxiety and depression in an outpatient setting (31). The HADS questionnaire has seven items each for depression and anxiety subscales. Scoring for each item ranges from zero to three, with three denoting highest anxiety or depression level. A total score of ≥8 points out of a possible 21 denotes considerable symptoms of anxiety or depression and a score ≥11 indicates a clinical case of anxiety or depression. If PERCS researchers have concerns for the psycho-social wellbeing of any participant, on the basis of these questionnaires or on other assessments findings, they will liaise with the Psycho-Oncology team in St James’s Hospital who can accept referrals or provide advice to the researchers as required. Qualitative Assessment At T1 assessments, a purposive sample of at least 20 participants will be invited to complete semi-structured interviews to examine their perceptions of the triage and referral system on their physical and psychosocial wellbeing, satisfaction with the system and barriers and facilitators to engagement with the system. The PERCS research team will interview participants who represent all three triage levels and mixed demographics to understand a breadth of participant experiences. The interview guide was developed using the Consolidated Framework for Implementation Research (CFIR) [40]. CFIR is an implementation framework consists of 37 constructs which are associated with successful implementation. By analysing an intervention against these constructs, the researcher can better understand the reasons why implementation was or was not successful [41] . CFIR constructs are clustered under five domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. PERCS researchers used the online CFIR interview guide development tool (https://cfirguide.org/guide/app/#/) to build a customised interview guide based on the CFIR constructs that are the focus of this implementation evaluation. Table 5 outlines the interview guide mapped against CFIR domains. No PERCS interview questions are mapped against the ‘process of implementation’ domain, as the four constructs in this domain (‘planning’, ‘engaging’, ‘executing’, ‘reflecting and evaluating’) are targeted to non-participant/user stakeholders, e.g. implementation leaders and opinion leaders. Interviews will be digitally audio-recorded and transcribed verbatim. Interview data will then be deductively analysed using pre-identified codes related to CFIR constructs, while also allowing for identification of new codes from the dataset [42, 43]. Table 5 Semi-structured interview guide, mapped against Consolidated Framework for Implementation Research (CFIR) domains and constructs CFIR domain CIFR construct Interview question* Intervention Characteristics Evidence Strength & Quality What are your overall thoughts about the PERCS system? What did you like/not like about PERCS? Relative Advantage Are you aware of other systems/services which support people to become more active after cancer? If so, can you please describe the system/service and what you think are its advantages? Design Quality & Packaging What are your thoughts on the quality of the written materials used in PERCS (PIL, diary)? Are there any changes you would recommend to these materials? Did you visit the PERCS webpage? If so, what are your thoughts on it? What did you find helpful / not helpful? Are there any changes you would recommend? Cost Did it cost you anything (financially) to take part in PERCS? If so, can you describe the costs? Outer Setting Patient Needs & Resources Please describe your overall experience of the PERCS service. Do you feel that the PERCS system and the PERCS team understand the needs and preferences of people who have had cancer treatment? Can you explain why? Do you think the PERCS system successfully meets the needs of people who have had cancer treatment? How? In general, how do you think people who have had cancer would respond to the PERCS system? Can you think of any reason or situation where someone would find it difficult to take part in the PERCS system? Is there any way we can make it easier for people to attend? Inner Setting Implementation Climate Do you think a system such as PERCS system is needed for people after cancer? Why/why not? What did your family / partner / friends think of the PERCS system? Tension for Change Are you aware of other systems/services which support people to become more active after cancer? If so, please describe. How do you think the other systems/services meet the needs of people after cancer? Characteristics of Individuals Self-efficacy Before you attended your first assessment, how confident did you feel that you would be able to use the PERCS system? Why did you feel this way? Individual State of Change Data obtained from Health Behaviour and Stages of Change Questionnaire at T0 & T1 *Order of questions in table relates to their relationship to CIFR dimensions; questions will be asked in an intuitive order at interview. CFIR: Consolidated Framework for Implementation Research, PERCS: Personalised Exercise Rehabilitation in Cancer Survivorship Data management and analysis A data management plan will outline how research data will be handled during and after the project. The data management plan is a live document and will be reviewed regularly throughout the study. Source documents for this study will include hospital records and the study’s data collection forms. Outcome assessments will be legibly and accurately recorded in a paper-based case report form, which will be stored in a locked, secure location only accessible by PERCS researchers. Data from the case report form will then be entered into a password protected computer data repository. All participants will be allocated a unique study code. The key to the study code will be stored securely and separately to other study data. Electronic records will be stored on password protected encrypted devices. Upon completion of the study an anonymised data set will be deposited on a secure online repository in line with open access publication requirements. Direct access will be granted to authorised representatives from the host institution, CRF and regulatory authorised to permit study-related monitoring, audits, and inspections. A descriptive analysis will be completed for relevant implementation outcomes. Summary statistics for continuous variables and categorical variables will be presented, with sub-group analysis as appropriate. Change in physical functioning and psychosocial outcomes from T0-T1 will be analysed used paired sample t-tests or the Wilcoxon test. Qualitative data will be deductively analysed using NVivo 11 (QSR International, Australia) qualitative data analysis software. Trial management and governance Management of the PERCS study is overseen by a trial management group who meet biannually as standard and more frequently in response to the needs of the study. The purpose of the trial management group is to: guide study conception and development of the study protocol; review and approve protocol amendments; advise on the methodology and review any relevant new information regarding the intervention or clinical area which may impact on the running of the trial; oversee the day-to-day running of the PERCS study; and ensure that the viewpoints of all stakeholder groups are considered. Membership of the trial management group includes the principal investigator, the clinical lead, the project manager, representatives from academic and clinical physiotherapy and psycho-oncology, and three patient representatives. Dissemination Findings of PERCS will be disseminated via peer-reviewed publications and conference presentations. Aggregate study results will be presented to participants and their families at an education symposium upon study completion. Anonymised data will be made available on an open access repository. Public and Patient Involvement Three individuals from the Trinity St James’s Cancer Institute Patient Representative Group sit on the trial management group and provide input into all aspects of the study. Patient representatives were extensively involved in the co-design of the PERCS website (www.cancerrehabilitation.ie), which will be available to all participants in this current study as an additional informational resource. Through an iterative process, based in user-centred design principles, patient representatives from a range of demographic and cancer-type backgrounds guided the development of this site. The patient needs identified in this co-design process also informed the execution of this current study, e.g. the need to provide user-friendly, easy-to-read written materials (participant information leaflets, exercise diaries). Discussion This study will investigate the real-world application of an exercise rehabilitation triage and referral system in cancer survivorship. The importance of triage and referral systems to support implementation of exercise rehabilitation into practice cannot be overstated. Appropriately triaging cancer survivors to the correct level of care for their needs is widely regarded as the basis of an efficient, effective stepped model of rehabilitation care [ 5 , 8 , 9 ]. While the PERCS triage and referral system is being pilot tested on a cohort of patients treated during the COVID-19 pandemic, the system has the potential to be applied at various point across the survivorship trajectory, and with numerous sub-populations of cancer survivors. The population and context of use will largely influence the outcomes of the triage system. For example, if applied during or soon after treatment, there would be more demand on ‘level 3’ services i.e. exercise rehabilitation with specialist healthcare professionals, as there will likely be a higher level of need in this group than in the cohort involved in this study, many of whom will be 2 years post-treatment. Other potential applications of this system include its use in people with specific cancer types, and application by other healthcare professionals, for example within a nursing-led clinic. This study is based upon a strong evidence base showing that exercise is beneficial for both the physical and psycho-social wellbeing of cancer survivors[ 3 ]. Physical and psycho-social outcomes will be completed for all participants, allowing us to identify a more holistic impact of exercise in this sample. Participants will have the opportunity to set targeted, meaningful goals within the clinic. This important health behaviour change technique can support engagement in physical activity [ 44 ], and, supplemented by use of the Patient Specific Functional Scale, can also show change in function or ability over time [ 36 ]. The physiotherapy-led clinic setting further supports the holistic management of cancer survivors, as referrals can be made to other members of the oncology multi-disciplinary team, addressing the wider needs of participants as needed. Conclusion Exercise rehabilitation triage and referral systems are widely recommended to support people living with and after cancer to become more active and to improve physical and psychosocial wellbeing. To support implementation in clinical settings, real-world evaluation of these systems are needed. The PERCS triage and referral system supports decision making in exercise rehabilitation referrals and could help address issues of under-resourced specialist rehabilitation services, directing patients to best level of support for their need. The PERCS triage and referral system could be applied in a wide range of contexts and this study will explore its application in a physiotherapy-led clinic with people who were diagnosed with cancer during the COVID-19 pandemic. Abbreviations ACSM: American College of Sports Medicine; BMI: Body Mass Index; Carer: Cancer Rehabilitation to Recreation; CFIR: Consolidated Framework for Implementation Research; CRF: Clinical Research Facility; ECOG-PS: Eastern Cooperative Oncology Group-Performance Status; EDI: Equality, Diversity, Inclusion; EORTC- QLQ-C30: European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire; EXCEEDS: Exercise in Cancer Evaluation and Decision Support; HRB: Health Research Board; IPAQ: International Physical Activity Questionnaire; MFI-20: Multidimensional Fatigue Inventory; MNA: Mini-Nutirional Assessment; NCCN: National Comprehensive Cancer Network; PERCS: Personalised Exercise Rehabilitation in Cancer Survivorship; QOL: quality of life; RE-AIM: Reach, Effectiveness, Adoption, Implementation, Maintenance. Declarations Acknowledgements The authors would like to acknowledge the assistance and support of the Wellcome/HRB Clinical Research Facility at St. James’ Hospital, Dublin. Thank you to all the patient representatives who provide expert insights and support across all stages of the PERCS study. Thank you to colleauges in the academic and healthcare settings, and to members of the PERCS Trial Management Group, for your support with developing the protocol and overseeing the study: Prof Deirdre Connolly, Dr Amy Dennett, Dr Suzanne Doyle, Cathy Enright, Robin Menzies, Sarah Wade, Niamh Murphy, Brendan Nagle, Dr Maria Pertl and Prof Suzanne Guerin. Authors contributions EG, GS, LB, JH, LON, CLD, PB and SC developed the study concept and protocol. LB and EG will oversee the implementation of the protocol, data collection and data analysis. All authors will contribute to interpretation of data. EG and LB drafted the manuscript, all authors contributed to revisions and all authors approved the final manuscript. Funding This work is funded by the Irish Cancer Society in partnership with the National Cancer Control Programme through the Research Grant COV21GUI. The funders have no direct role in the design, conduct or analysis of the project. Availability of data and materials The datasets used and analysed during the current study available from the corresponding author on reasonable request. Ethical approval and consent to participate The Principal Investigator will ensure that the study is conducted in accordance with the ethical principles that have their origins in the Declaration of Helsinki. This study will be conducted in accordance with Good Clinical Practice (GCP), as defined by the International Conference on Harmonisation (ICH) and in accordance with the ethical principles underlying European Union Directive 2001/20/EC and 2005/28 EC. Ethical approval has been granted by the Tallaght University Hospital/St James’s Hospital Research Ethics Committee. All participants are required to provide written informed consent. The research ethics committee will be informed of any modifications to the study protocol. Consent for publication Not applicable Competing interests Dr. Emer Guinan is a member of the editorial board (Associate Editor) of this journal. Other authors have no competing interests to disclose Author details Department of Surgery, School of Medicine, Trinity College Dublin, Ireland Trinity St James’s Cancer Institute, Dublin, Ireland Department of Physiotherapy, St James’s Hospital, Dublin, Ireland Psycho-Oncology Unit, St. James's Hospital, Dublin, Ireland Trinity St James's Cancer Institute Patient Representative Group, Trinity St James’s Cancer Institute, Dublin, Ireland Department of Surgery, St James’s Hospital, Dublin, Ireland Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland References Nurgali K, Jagoe RT, Abalo R: Editorial: Adverse Effects of Cancer Chemotherapy: Anything New to Improve Tolerance and Reduce Sequelae? Front Pharmacol 2018, 9 :245. Mehnert A, Scherwath A, Schirmer L, Schleimer B, Petersen C, Schulz-Kindermann F, Zander AR, Koch U: The association between neuropsychological impairment, self-perceived cognitive deficits, fatigue and health related quality of life in breast cancer survivors following standard adjuvant versus high-dose chemotherapy . Patient Educ Couns 2007, 66 (1):108-118. Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, Zucker DS, Matthews CE, Ligibel JA, Gerber LH et al : Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable . Med Sci Sports Exerc 2019, 51 (11):2375-2390. Hayes SC, Newton RU, Spence RR, Galvao DA: The Exercise and Sports Science Australia position statement: Exercise medicine in cancer management . J Sci Med Sport 2019. Schmitz KH, Campbell AM, Stuiver MM, Pinto BM, Schwartz AL, Morris GS, Ligibel JA, Cheville A, Galvão DA, Alfano CM et al : Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer . CA: a cancer journal for clinicians 2019, 69 (6):468-484. Schmitz KH, Stout NL, Maitin-Shepard M, Campbell A, Schwartz AL, Grimmett C, Meyerhardt JA, Sokolof JM: Moving through cancer: Setting the agenda to make exercise standard in oncology practice . Cancer 2020. Brennan L, Sheill G, O'Neill L, O'Connor L, Smyth E, Guinan E: Physical Therapists in Oncology Settings: Experiences in Delivering Cancer Rehabilitation Services, Barriers to Care, and Service Development Needs . Phys Ther 2022, 102 (3). Alfano CM, Cheville AL, Mustian K: Developing High-Quality Cancer Rehabilitation Programs: A Timely Need . 2016(1548-8756 (Electronic)). Covington KR, Marshall T, Campbell G, Williams GR, Fu JB, Kendig TD, Howe N, Alfano CM, Pergolotti M: Development of the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) algorithm . Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer 2021, 29 (11):6469-6480. Mina DS, Sabiston CM, Au D, Fong AJ, Capozzi LC, Langelier D, Chasen M, Chiarotto J, Tomasone JR, Jones JM et al : Connecting people with cancer to physical activity and exercise programs: a pathway to create accessibility and engagement . Curr Oncol 2018, 25 (2):149-162. Dennett AM, Peiris CL, Shields N, Taylor NF: From Cancer Rehabilitation to Recreation: A Coordinated Approach to Increasing Physical Activity . Phys Ther 2020, 100 (11):2049-2059. Rimmer J, Lai B: Framing new pathways in transformative exercise for individuals with existing and newly acquired disability . Disabil Rehabil 2017, 39 (2):173-180. Barnett J, Vasileiou K, Djemil F, Brooks L, Young T: Understanding innovators' experiences of barriers and facilitators in implementation and diffusion of healthcare service innovations: a qualitative study . BMC Health Serv Res 2011, 11 :342. McLaughlin KH, Simon L, Friedman M, Siddiqui ZK, Ficke JR, Kantsiper ME: Lessons Learned From Implementing Rehabilitation at a COVID-19 Field Hospital . Am J Phys Med Rehabil 2021, 100 (11):1027-1030. Riebe D, Franklin BA, Thompson PD, Garber CE, Whitfield GP, Magal M, Pescatello LS: Updating ACSM's Recommendations for Exercise Preparticipation Health Screening . Med Sci Sports Exerc 2015, 47 (11):2473-2479. Dunphy C, McNeely ML: Growing the Workforce in Oncology Physical Therapy: From Entry Level to Specialist Care . Rehabilitation Oncology 2022, 40 (1):5-6. Mulcahy S, Prendergast J, Foley G, A OH, Murphy E, Guinan EM, Hussey J: Exercise Rehabilitation Services Provided by Physiotherapy Departments in Cancer Care in Ireland . Irish medical journal 2018, 111 (9):818. Shipton DA, Dennett AM, Sayner AM, Tang CY: A national survey of oncology physiotherapy services for cancer survivors in Australia . Asia Pac J Clin Oncol 2022, 18 (5):e404-e413. Kennedy MA, Bayes S, Newton RU, Zissiadis Y, Spry NA, Taaffe DR, Hart NH, Galvão DA: Implementation barriers to integrating exercise as medicine in oncology: an ecological scoping review . J Cancer Surviv 2022, 16 (4):865-881. Nekhlyudov L, Duijts S, Hudson SV, Jones JM, Keogh J, Love B, Lustberg M, Smith KC, Tevaarwerk A, Yu X et al : Addressing the needs of cancer survivors during the COVID-19 pandemic . J Cancer Surviv 2020, 14 (5):601-606. Poghosyan H, Margaryan Y, Jeon S, Edelman EJ, Yu JB: Association between social connectedness and stress or anxiety among older cancer survivors during the 2020-2021 winter surge of the COVID-19 pandemic . Journal of geriatric oncology 2023, 14 (1):101390. Brown M, O'Connor D, Murphy C, McClean M, McMeekin A, Prue G: Impact of COVID-19 on an established physical activity and behaviour change support programme for cancer survivors: An exploratory survey of the Macmillan Move More service for Northern Ireland . Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer 2021:1-9. Mina DS, Langelier D, Adams SC, Alibhai SMH, Chasen M, Campbell KL, Oh P, Jones JM, Chang E: Exercise as part of routine cancer care . Lancet Oncol 2018, 19 (9):e433-e436. NCCN: National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology - Survivorship . 2018. Podsiadlo D, Richardson S: The timed "Up & Go": a test of basic functional mobility for frail elderly persons . J Am Geriatr Soc 1991, 39 (2):142-148. Azam F, Latif MF, Farooq A, Tirmazy SH, AlShahrani S, Bashir S, Bukhari N: Performance Status Assessment by Using ECOG (Eastern Cooperative Oncology Group) Score for Cancer Patients by Oncology Healthcare Professionals . Case Rep Oncol 2019, 12 (3):728-736. Shumway-Cook A, Brauer S, Woollacott M: Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test . Phys Ther 2000, 80 (9):896-903. Glasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, Ory MG, Estabrooks PA: RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review . Front Public Health 2019, 7 :64. Oyer RA, Hurley P, Boehmer L, Bruinooge SS, Levit K, Barrett N, Benson A, Bernick LA, Byatt L, Charlot M et al : Increasing Racial and Ethnic Diversity in Cancer Clinical Trials: An American Society of Clinical Oncology and Association of Community Cancer Centers Joint Research Statement . Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2022, 40 (19):2163-2171. European Handbook on Equality Data (2016 revision) file:///C:/Users/guinane1/Downloads/european_handbook_on_equality_63B98CA7-CDBA-9BB3-903A6A3781B5F5E3_43205.pdf . In . Hagströmer M, Oja P, Sjöström M: The International Physical Activity Questionnaire (IPAQ): a study of concurrent and construct validity . Public Health Nutr 2006, 9 (6):755-762. Gonzalez-Ramirez LP, De la Roca-Chiapas JM, Colunga-Rodriguez C, Preciado-Serrano ML, Daneri-Navarro A, Pedroza-Cabrera FJ, Martinez-Arriaga RJ: Validation of Health Behavior and Stages of Change Questionnaire . Breast Cancer (Dove Med Press) 2017, 9 :199-205. Wilcox S, Sharpe PA, Hutto B, Granner ML: Psychometric properties of the self-efficacy for exercise questionnaire in a diverse sample of men and women . Journal of Physical Activity and Health 2005, 2 (3):285-297. Resnick B, Jenkins LS: Testing the reliability and validity of the Self-Efficacy for Exercise scale . Nurs Res 2000, 49 (3):154-159. Forrest KYZ, Williams AM, Leeds MJ, Robare JF, Bechard TJ: Patterns and Correlates of Grip Strength in Older Americans . Current aging science 2018, 11 (1):63-70. Stratford PW, Gill C, Westaway M, Binkley J: Assessing Disability and Change on Individual Patients: A Report of a Patient Specific Measure . Physiotherapy Canada 1995, 47 (4):258-263. ATS statement: guidelines for the six-minute walk test . American journal of respiratory and critical care medicine 2002, 166 (1):111-117. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC et al : The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology . J Natl Cancer Inst 1993, 85 (5):365-376. Smets EM, Garssen B, Bonke B, De Haes JC: The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue . Journal of psychosomatic research 1995, 39 (3):315-325. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC: Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science . Implement Sci 2009, 4 :50. King DK, Shoup JA, Raebel MA, Anderson CB, Wagner NM, Ritzwoller DP, Bender BG: Planning for Implementation Success Using RE-AIM and CFIR Frameworks: A Qualitative Study . Front Public Health 2020, 8 :59. Nevedal AL, Reardon CM, Opra Widerquist MA, Jackson GL, Cutrona SL, White BS, Damschroder LJ: Rapid versus traditional qualitative analysis using the Consolidated Framework for Implementation Research (CFIR) . Implement Sci 2021, 16 (1):67. Damschroder LJ, Lowery JC: Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR) . Implement Sci 2013, 8 :51. Agbadjé TT, Elidor H, Perin MS, Adekpedjou R, Légaré F: Towards a taxonomy of behavior change techniques for promoting shared decision making . Implement Sci 2020, 15 (1):67. Additional Declarations Competing interest reported. Dr. Emer Guinan is a member of the editorial board (Associate Editor) of this journal. Other authors have no competing interests to disclose Cite Share Download PDF Status: Published Journal Publication published 23 Apr, 2024 Read the published version in BMC Cancer → Version 1 posted Editorial decision: Revision requested 14 Mar, 2024 Reviews received at journal 07 Nov, 2023 Reviewers agreed at journal 31 Oct, 2023 Reviewers agreed at journal 23 Oct, 2023 Reviewers invited by journal 11 Oct, 2023 Editor assigned by journal 11 Oct, 2023 Editor invited by journal 31 Aug, 2023 Submission checks completed at journal 31 Aug, 2023 First submitted to journal 17 Jul, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3178374","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":230105159,"identity":"3ad054e0-9bed-4a11-8da4-210ecbb22404","order_by":0,"name":"Louise Brennan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArUlEQVRIiWNgGAWjYBACAzBZIMHDD6QkoFxitBhYyEm2kailwtjgGEgLMcBc+vCxxwUGEomb7zc/vMFQYENYi2VfWrrxDKCWbcfYjC0YDNKIcNgZHjNpHrAWHjagXw4To4X/G1jL5jawlv9E2cIG0mJswAbWcoCwFsseNrDD5CSOpRlbJBgkE9ZizsP8TJqnoo6Hv/nwwxsf/tgR1oIKEkjVMApGwSgYBaMAOwAAnscr1ZepdXIAAAAASUVORK5CYII=","orcid":"","institution":"Trinity College Dublin","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Louise","middleName":"","lastName":"Brennan","suffix":""},{"id":230105160,"identity":"0746a6bb-5a31-49bb-b076-b59f9d71affb","order_by":1,"name":"Grainne Sheill","email":"","orcid":"","institution":"St James’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Grainne","middleName":"","lastName":"Sheill","suffix":""},{"id":230105161,"identity":"259fb0ba-22fd-41f0-81b8-e18025472a00","order_by":2,"name":"Sonya Collier","email":"","orcid":"","institution":"St James’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sonya","middleName":"","lastName":"Collier","suffix":""},{"id":230105162,"identity":"15786e62-1e57-4f23-ae90-e3642b72f47d","order_by":3,"name":"Peter Browne","email":"","orcid":"","institution":"Trinity St James’s Cancer Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Browne","suffix":""},{"id":230105163,"identity":"ce4cd8d7-e35f-41e1-bbb7-88e4b2e9f43a","order_by":4,"name":"Claire L. Donohoe","email":"","orcid":"","institution":"St James’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Claire","middleName":"L.","lastName":"Donohoe","suffix":""},{"id":230105164,"identity":"387a7ed4-5d53-4739-8010-beff94ae546d","order_by":5,"name":"Linda O’Neill","email":"","orcid":"","institution":"Trinity College Dublin","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Linda","middleName":"","lastName":"O’Neill","suffix":""},{"id":230105165,"identity":"a9f55b17-c926-4194-b6ea-37ae33f73d1f","order_by":6,"name":"Juliette Hussey","email":"","orcid":"","institution":"Trinity College Dublin","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Juliette","middleName":"","lastName":"Hussey","suffix":""},{"id":230105166,"identity":"fa9efb45-5847-4133-830b-b7a89057458a","order_by":7,"name":"Emer Guinan","email":"","orcid":"","institution":"Trinity College Dublin","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Emer","middleName":"","lastName":"Guinan","suffix":""}],"badges":[],"createdAt":"2023-07-17 14:31:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3178374/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3178374/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12885-024-12266-x","type":"published","date":"2024-04-23T22:39:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":42678373,"identity":"bfb79ec6-6ba9-430f-95c3-0f1b770dc8ca","added_by":"auto","created_at":"2023-09-06 01:15:23","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":154633,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of study design\u003c/p\u003e","description":"","filename":"floatimage1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3178374/v1/fb6ba329b2e3d35178292086.jpg"},{"id":42678372,"identity":"41a6bcf4-bf07-453a-9715-bfa3b4f19979","added_by":"auto","created_at":"2023-09-06 01:15:23","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":195671,"visible":true,"origin":"","legend":"\u003cp\u003ePERCS triage and referral system\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3178374/v1/f36f006030b8653905a7d2e0.jpeg"},{"id":55690442,"identity":"092c28c1-6ca0-4551-8494-6ce6a6091d60","added_by":"auto","created_at":"2024-05-01 22:39:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2255839,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3178374/v1/ee563e07-fcff-480b-a725-d2eac1386ba4.pdf"}],"financialInterests":"Competing interest reported. Dr. Emer Guinan is a member of the editorial board (Associate Editor) of this journal. Other authors have no competing interests to disclose","formattedTitle":"Personalised Exercise Rehabilitation in Cancer Survivorship: The PERCS Triage and Referral System Study Protocol","fulltext":[{"header":"Background","content":"\u003cp\u003eThe immediate and long-term sequelae of cancer treatment, including cardiopulmonary deconditioning, impaired bone health, altered body composition, and increased rates of fatigue, depression and anxiety is well-documented [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Compelling evidence from randomised clinical trials shows aerobic and resistance exercise training can have positive impact across numerous physical and psychosocial outcomes including anxiety, depression, cancer-related fatigue, health-related quality of life (QOL) and self-reported physical functioning [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This evidence was synthesised in the 2019 American College of Sports Medicine (ACSM) Exercise Guidelines for Cancer Survivors, which presented the minimal recommended levels of physical activity for cancer survivors as: 30 minutes of moderate intensity aerobic exercise three times per week and twice-weekly resistance training [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These guidelines support exercise prescription for all people living with and after cancer.\u003c/p\u003e \u003cp\u003eInternationally, expert groups have called for better integration of exercise rehabilitation into cancer care pathways [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. To effectively translate the ACSM Exercise Guidelines research into practice, the development of a collaborative, coordinated system between hospital-based and community-based programmes, with established referral pathways enabling access to rehabilitative care from diagnosis to the post-treatment period is recommended. This should be underpinned by a stepped model of care that directs patients to the right level of service to meet their individual needs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Currently, this model of care remains aspirational in most healthcare systems [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Research by our group finds that, in Ireland, people with and after cancer frequently do not receive support to enable them to become more physically active due to under-resourced and disjointed acute and community services, and a lack of information and awareness by both patients and the oncology multi-disciplinary team [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePeople living with and after cancer need a range of exercise rehabilitation services, and the level of professional support or supervision required depends on factors such as level of impairment, co-morbidities, and exercise-related self-efficacy. Within a stepped model of care, exercise rehabilitation can be categorised into different \u0026lsquo;levels\u0026rsquo;, which are typically classified as i) unsupervised, unspecialised exercise rehabilitation; ii). supervised, community-based exercise rehabilitation, broadly specialised to those with a history of cancer or chronic disease; iii). highly specialised exercise rehabilitation, supervised by a specialist healthcare professional [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A screening approach which triages people according to their level of need and directly refers to the most suitable exercise rehabilitation service can contribute to a patient-centred, efficient pathway of care, and can prioritise specialist services for those who most need them [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are exciting ongoing efforts internationally to develop stepped-care models and triage and referral systems for exercise rehabilitation in cancer survivorship. The Cancer Rehabilitation to Recreation (CaReR) Framework [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] aims to increase physical activity after cancer through a three-phase framework spanning Rehabilitation, Fitness and Recreation. The framework does not include a triage system to support decision making in identifying which phase of the framework best meets a patient\u0026rsquo;s needs. The theoretical model, which is proposed as an amalgamation of the Stepped Care Framework and the Transformative Exercise Framework [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], incorporates different levels of clinical oversight, from fitness professional to physiotherapist, along a spectrum of physical activity counselling across hospital and community settings. Fitness professionals can play an important and impactful role in exercise rehabilitation of cancer survivors with lower levels of impairment, by delivering exercise programmes which are generally community-based and more accessible and affordable than programmes in healthcare settings [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Physiotherapy-delivered programmes are most suitable for patients with cancer-related comorbidities or physical impairments [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Physiotherapists are core members of the oncology multi-disciplinary team who specialise in rehabilitation and exercise prescription, [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and can assess and manage many of the common physical side effects of cancer treatment such as weakness, cachexia, fatigue, loss of balance, lymphoedema and pain [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In a recent qualitative analysis of semi-structured interviews with oncology-specialist physiotherapists in Ireland, physiotherapists called for all cancer survivors to have access to a physiotherapy assessment and for greater emphasis on improving QOL within cancer care but reported a lack of funding and resources to address patient needs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Exercise in Cancer Evaluation and Decision Support (EXCEEDS) triage model is a two-part decision support tool designed to be used at the point of care by multi-disciplinary users. EXCEEDS evaluates cancer survivors\u0026rsquo; physical activity levels and chronic disease risks and recommends an appropriate level of exercise service: cancer rehabilitation, clinically supervised exercise, supervised community-based cancer specific exercise or unsupervised, generic community-based exercise [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The EXCEEDS algorithm has not yet been evaluated in practice and the triage outcomes may be difficult to implement in Ireland, where there is limited provision of supervised exercise programmes for cancer survivors in community- and healthcare-based settings (both public and private) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This situation is not dissimilar to the situation in many countries where exercise rehabilitation services for cancer survivors are only starting to develop [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. There is a need for an exercise rehabilitation triage and referral system which will work in a country with limited cancer rehabilitation resources [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo be effectively implemented, triage and referral systems should be easily and rapidly applicable in practice, should be adaptable to different clinical contexts, and should optimally utilise the services available in the local healthcare setting [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In line with the best available evidence in exercise oncology, such a system should be based on the 2019 ACSM guidelines for exercise in patients in cancer, and should consider patients\u0026rsquo; current levels of physical activity (both pre- and post-cancer treatment) while also being sensitive to identify possible individual risks of increasing physical activity [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn June 2021, the Irish Cancer Society, in partnership with the National Cancer Control Programme in Ireland, launched the COVID-Cancer Rapid Response Award. The aim was to identify evidence-based mitigations for the burdens brought about by the COVID-19 pandemic on people living with or beyond cancer in Ireland. The pandemic had profound physical and psychosocial effects on the general population and there are major concerns that cancer survivors may be disproportionally impacted [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Internationally, there was a high prevalence of psychological strain, stress and isolation among cancer survivors during this period [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In Northern Ireland, 61% of previously active cancer survivors, reported a psychosocial impact of the COVID-19 restrictions including loneliness, lack of social support, decreased motivation to exercise, fear, anxiety and depression, while 32% reported a physical impact including deterioration in health and fitness, increased pain and body weight, and changes in dietary habits habits[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Alongside the existing need to make evidence-based exercise rehabilitation a priority for cancer care, there is now an additional, urgent need to mitigate the dual impact of cancer treatment and COVID-19 on physical and psychosocial health.\u003c/p\u003e \u003cp\u003eThe Personalised Exercise Rehabilitation in Cancer Survivorship (PERCS) study, which is funded through the COVID-Cancer Rapid Response Award, will test the real-world application of an exercise rehabilitation triage and referral system within a physiotherapy-led cancer rehabilitation clinic. The system aims to improve physical activity levels in participants by optimally utilising existing exercise rehabilitation services, particularly those in the community, while reserving specialist exercise rehabilitation services delivered by physiotherapists for patients who require a more specialised level of care. The triage and referral system will be applied with people who received cancer treatment during the height of the COVID-19 pandemic, with a view to providing additional supports to this group who experienced exceptional challenges during their treatment.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy aims\u003c/h2\u003e\n\u003cp\u003eThe overall aim of this study is to evaluate the real-world application of an exercise rehabilitation triage and referral system on physical and psychosocial outcomes in cancer survivors treated during the COVID-19 pandemic. The triage and referral system will be delivered within the context of a physiotherapy-led cancer rehabilitation clinic in a specialist national cancer centre.\u003c/p\u003e\n\u003cp\u003eThe study objectives are to:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eApply an exercise rehabilitation triage and referral system for cancer survivors in a single specialist cancer centre\u003c/li\u003e\n \u003cli\u003eDescribe the real-world implementation of the triage and referral system\u003c/li\u003e\n \u003cli\u003eEvaluate change in real-world physical functioning outcomes and psychosocial outcomes after 12 weeks following application of the triage and referral system\u003c/li\u003e\n \u003cli\u003eQualitatively evaluate impact on health-related QOL, patient experience and psychosocial outcomes after 12 weeks following application of the triage and referral system\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eThis study will use a pre-post-test design to examine the real-world application of an exercise rehabilitation triage and referral system for cancer survivors. The exercise rehabilitation triage and referral system will be applied following a baseline assessment (T0) and will guide patient referral to one of three exercise rehabilitation pathways (Figure 1). A follow-up assessment will be completed after 12-weeks (T1). The study will take place in the Wellcome-Health Research Board (HRB) Clinical Research Facility (CRF) at St James\u0026rsquo;s Hospital, Dublin. Ethical approval has been obtained from the Tallaght University Hospital/ St James\u0026rsquo;s Hospital Joint Research Ethics Committee (Study ID 0670) and hospital approval to conduct research from the Research and Innovation Office at St James\u0026rsquo;s Hospital. Any amendment to the protocol which may impact on the conduct of the study will be submitted as an amendment for approval to the ethics committee. PERCS study was registered with ClinicalTrials.gov on 14/11/2022, trial identifier NCT05615285 and will be performed according to the Declaration of Helsinki.\u003c/p\u003e\n\u003ch2\u003eStudy participants\u003c/h2\u003e\n\u003cp\u003ePERCS will recruit up to 100 patients who have been diagnosed with cancer at St James\u0026rsquo;s Hospital between March 2020 and March 2022. St James\u0026rsquo;s Hospital is the largest cancer centre in Ireland with high-volume national, supra-regional and regional teams and structures for multiple malignancies and dedicated cancer prehabilitation and rehabilitation pathways managed by a team of clinical specialist physiotherapists.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants must meet the following eligibility criteria: have completed adjuvant chemotherapy and/or radiotherapy; be at least 6 weeks post-surgery; do not show signs of recurrent or metastatic disease at the time of enrolment; be over the age of 18 years; be able to provide written informed consent.\u003c/p\u003e\n\u003cp\u003eClearance to participate in exercise, as determined by the ACSM preparticipation health screening recommendations, will be a pre-requisite for undergoing the exercise rehabilitation triage and referral system [15]. Clearance from a general practitioner or consultant to participate in the study will be required if initial assessment or study pre-screening identifies any of the following conditions: known and symptomatic cardiovascular, metabolic, or renal disease; signs or symptoms suggestive of cardiovascular, metabolic, or renal disease; and recognised precautions for exercise [15, 23].\u003c/p\u003e\n\u003ch2\u003eScreening and Recruitment\u003c/h2\u003e\n\u003cp\u003ePotential participants will be identified by the clinical cancer prehabilitation and rehabilitation physiotherapy team from a database of patients who were referred to the OpFit Cancer Prehabilitation programme at St James\u0026rsquo;s Hospital, beginning from March 2020. Further eligibility screening will be completed by the research team. Potential participants will be sent a letter of invitation to participate, which will include a participant information leaflet (PIL) and a cover letter including contact details for the study team. One week after the anticipated arrival date of this letter, a member of the research team will follow up with a phone call to answer any questions, to confirm if the person is or is not interested in participating in the study, and, where applicable, obtain verbal consent to participate and schedule an initial assessment. Full written consent in duplicate will be obtained at the T0 assessment, after which an entry will be made on the participant\u0026rsquo;s electronic patient record that they are participating in the study and their General Practitioner will be informed by letter. Individuals who decline participation will have the opportunity to consent to providing information on their demographics, physical activity levels, reasons for declining, and equality, diversity and inclusion metrics to help the research team understand the population who did not participate. A separate written informed consent form will be completed for this data collection.\u003c/p\u003e\n\u003ch2\u003ePERCS Exercise Rehabilitation Triage and Referral System\u003c/h2\u003e\n\u003cp\u003eThe PERCS exercise rehabilitation triage and referral system was developed by the PERCS research team and an overview is presented in Figure 2. The system involves:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eGathering specific information through patient assessment\u003c/li\u003e\n \u003cli\u003eCompleting triage questions to inform a decision on the best level of exercise rehabilitation for a patient\u003c/li\u003e\n \u003cli\u003eA discussion of triage outcome with the patient, collaborative creation of a physical activity plan, and making any required referrals to exercise rehabilitation services.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTo complete the PERCS exercise rehabilitation triage and referral system, an assessment must be conducted to gather, at a minimum, the following information: past medical history, physical activity levels, Timed Up \u0026amp; Go (TUG) and Eastern Cooperative Oncology Group Performance-Status (ECOG-PS). Two triage questions use assessment information to guide the user to one of three recommended pathways (\u0026lsquo;triage levels\u0026rsquo;) for exercise rehabilitation advice and onward referral (Figure 2) [3, 5]. The assessor will inform participants of their triage level, and a plan for physical activity over the coming 12 weeks will be developed in collaboration with the participant, including making a referral as needed. In this study, the triage system will be completed again at T1 to assess for (i) triage level recategorisation and (ii) change in individual component items. Onward referral will not be performed at T1.\u003c/p\u003e\n\u003ch3\u003eTriage question 1: Physical activity assessment\u003c/h3\u003e\n\u003cp\u003eQuestion 1 identifies whether patients do or do not require additional support to become more physically active by asking if they are currently meeting the recommended levels pf physical activity according to the ACSM Consensus Statement for Exercise Prescription in Cancer Survivors\u0026nbsp;[3]. The PERCS triage and referral system considers participants who are physically active at a moderate aerobic intensity for 30 minutes, 3 times per week as adherent to physical activity guidelines for aerobic exercise, and those completing at least twice weekly resistance exercise for 30 minutes as adherent to physical activity guidelines for resistance training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo evaluate current adherence to physical activity guidelines, two questions will be asked, as recommended by Schmitz et al. (2019)\u0026nbsp;[5]: \u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eHow many days during the past week have you performed physical activity where your heart beats faster and your breathing is harder than normal for 30 minutes or more?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHow many days during the past week have you performed physical activity to increase muscle strength, such as lifting weights?\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch3\u003eTriage Question 2: Assess level of supervision needed\u003c/h3\u003e\n\u003cp\u003eQuestion 2 seeks to identify if patients require support to become more active from a healthcare professional or from a fitness professional. Participants at heightened risk for adverse events associated with increasing current physical activity levels are identified by evaluation using the triage approach adapted by Campbell et al. from the National Comprehensive Cancer Network (NCCN) Survivorship Guidelines (Table 1) [3, 24], the TUG [25] and the ECOG-PS assessment of a patient\u0026rsquo;s level of functioning [26]. Increased risk of adverse events as identified by any one of these three outcomes will lead the assessor to make a referral to a health professional for a specialist level of support in becoming more physically active.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Adapted National Comprehensive Cancer Network triage approach based on risk of exercise-induced adverse events[3, 24]\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.814332247557005%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription of Patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.185667752442995%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEvaluation, prescription, and programming recommendations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.814332247557005%\"\u003e\n \u003cp\u003eNo comorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.185667752442995%\"\u003e\n \u003cp\u003eNo further pre-exercise medical evaluation.\u003c/p\u003e\n \u003cp\u003eFollow general exercise recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.814332247557005%\"\u003e\n \u003cp\u003ePeripheral neuropathy, arthritis/musculoskeletal issues, poor bone health (e.g., osteopenia or osteoporosis), lymphoedema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.185667752442995%\"\u003e\n \u003cp\u003ePre-exercise medical evaluation recommended. Modify general exercise recommendations based on assessments. Consider referral to trained personnel.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.814332247557005%\"\u003e\n \u003cp\u003eLung or abdominal surgery, ostomy, cardiopulmonary disease, ataxia, extreme fatigue, severe nutritional deficiencies, worsening/changing physical condition (e.g., lymphoedema exacerbation), bone metastases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.185667752442995%\"\u003e\n \u003cp\u003ePre-exercise medical evaluation and clearance by a physician before commencing exercise.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eReferral to trained personnel.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch4\u003eCo-morbidity Status\u003c/h4\u003e\n\u003cp\u003eCo-morbidity status will be evaluated using NCCN triage approach based on risk of exercise-induced adverse events contained within their Survivorship Guidelines [24]. Disease-specific and treatment related side-effects which are considered to increase risk of exercise-induced adverse events will be identified in assessment using a standardised case report form.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eFalls Risk\u003c/h4\u003e\n\u003cp\u003eThe Timed Up and Go test is a reliable measure of functional mobility, balance and falls risk. It records the time in seconds it takes for a participant to stands up from a chair, walk 3m, turn back and sit in the chair. A faster time indicates better functional mobility, and a cut-off of 13.5 seconds is indicative of older adults at heightened falls risk [27].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEastern Cooperative Oncology Group-Performance Status\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ECOG-PS is a method of assessing the functional status of a patient that is widely used in oncology, particularly clinical trials, to define the population of patients to be studied in a trial, and track change in a patient\u0026rsquo;s level of functioning due to treatment during a trial (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eEastern Cooperative Oncology Group- Performance Status (ECOG-PS)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.48585690515807%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"91.51414309484193%\"\u003e\n \u003cp\u003e\u003cstrong\u003eECOG-PS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.48585690515807%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"91.51414309484193%\"\u003e\n \u003cp\u003eFully active, able to carry on all pre-disease performance without restriction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.48585690515807%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"91.51414309484193%\"\u003e\n \u003cp\u003eRestricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.48585690515807%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"91.51414309484193%\"\u003e\n \u003cp\u003eAmbulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.48585690515807%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"91.51414309484193%\"\u003e\n \u003cp\u003eCapable of only limited selfcare; confined to bed or chair more than 50% of waking hours\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.48585690515807%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"91.51414309484193%\"\u003e\n \u003cp\u003eCompletely disabled; cannot carry on any selfcare; totally confined to bed or chair\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.48585690515807%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"91.51414309484193%\"\u003e\n \u003cp\u003eDead\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003eTriage and Referral System Outcomes\u003c/h3\u003e\n\u003cp\u003eThe outcome of the Triage and Referral system is discussed by the physiotherapist and participant at the end of the assessment appointment. The triage and referral system leads to three possible outcomes:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTriage Level 1:\u003c/strong\u003e Participants who are currently meeting recommend levels of physical activity will be advised by the physiotherapist to continue with their current physical activity. Participants who want to increase their physical activity to achieve a particular goal will receive advice but will not be referred to a service.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTriage Level 2:\u003c/strong\u003e Participants who are not currently exercising to recommended levels and do not require medical supervision to exercise will be referred to a \u0026lsquo;local exercise service\u0026rsquo;, which is led by an exercise or fitness professional who is not a healthcare professional. Examples of local exercise services run by fitness professionals are: exercise programmes which are run specifically for cancer survivors, chronic disease populations or older adults; online exercise classes for chronic disease populations; a suitable local fitness class; or an exercise service provided by a community cancer support centre (charity-based).\u003c/p\u003e\n\u003cp\u003eThe choice of programme will be decided in collaboration with the participant, taking into account their preference for exercise modality, service location, and other accessibility factors such as time, duration, and frequency. The PERCS physiotherapist will provide contact details of the selected programme, will make a referral where needed and will encourage self-referral where possible. To aid communication with fitness professionals, a standardised information sheet will be provided to participants outlining the results of the PERCS assessment, stating low risk of adverse events with exercise, and providing contact details for the PERCS physiotherapist.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTriage Level 3:\u003c/strong\u003e Participants who are not currently exercising to recommended levels and who are deemed to require medical supervision to exercise, will be referred via the electronic patient record system to the Clinical Specialist Physiotherapist in Cancer Rehabilitation at St James\u0026rsquo;s Hospital (co-author GS) who will manage the referral through her clinical pathway. This may involve online or face-to-face assessment, online or face-to-face treatment sessions/exercise class sessions, discussion with the multidisciplinary team or onward referral to primary care physiotherapy services. The interventions provided by the Clinical Specialist Physiotherapist in Cancer Rehabilitation will be individualised to each participant based on clinical judgement and assessment.\u003c/p\u003e\n\u003cp\u003eAll participants will be advised to visit the PERCS website (www.cancerrehabilitation.ie), which was co-designed with patient representatives at the start of the PERCS study. The aim of the website is to be a national online resource for information on physical activity and cancer. The website contains concise, reliable information from trusted sources, aerobic and resistance training videos, and a national directory of exercise rehabilitation services which are suitable for people living with and after cancer. All participants will receive a follow-up telephone call one week post T0 assessment to answer any questions and support engagement in the recommended pathway. Further phone calls will be scheduled if required to support the participant with their referral pathway, e.g. to ensure referrals were received.\u003c/p\u003e\n\u003ch3\u003eContext of Implementation\u003c/h3\u003e\n\u003cp\u003eFor the purposes of this real-world implementation study, the exercise rehabilitation triage and referral system will be applied within the context of a physiotherapist-led \u0026lsquo;Cancer Rehabilitation Clinic\u0026rsquo;. In this context, the physiotherapist will apply a biopsychosocial approach to assessments, identifying holistic needs of participants, setting appropriate patient-centred goals and developing local referral pathways internally and externally to support a diverse range of rehabilitation needs.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003ch4\u003ePrimary Outcomes: Real-world implementation\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003ePERCS primary outcomes relate to evaluating the real-world application of the Triage and Referral System, namely, an implementation analysis using RE-AIM planning and evaluation framework (Table 3) [28]. The RE-AIM framework consists of five dimensions: Reach, Effectiveness, Adoption, Implementation and Maintenance, which help to plan programmes with greater external validity, improve the chances of a programme working in a real-world setting and identify the relative strengths and weakness of an approach. Three dimensions of RE-AIM will be applied to this project: Reach, Effectiveness and Implementation. In this feasibility study, adoption or maintenance of the system will not be assessed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Implementation outcomes for PERCS study\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplementation construct\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cstrong\u003eImplementation outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRE-AIM dimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRate of eligibility for recruitment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePercentage of patients on prehabilitation list who are eligible\u003c/li\u003e\n \u003cli\u003ePercentage of referrals to the study from clinical team who are eligible\u003c/li\u003e\n \u003cli\u003eReasons for ineligibility\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eReach\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnrolment rate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePercentage of people enrolled in study from those who were approached for recruitment.\u003c/li\u003e\n \u003cli\u003eReasons for declining participation\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eReach\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eSocio-demographics, medical history and cancer history, inclusion, equality and diversity characteristics of participants.\u003c/li\u003e\n \u003cli\u003eCompare to non-participant data, where possible\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eReach\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssessment attendance rates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePercentage of participants attending scheduled assessments at T0 and T1\u003c/li\u003e\n \u003cli\u003eReason for non-attendance\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eReach,\u003c/p\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttrition rates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePercentage of participants who did or did not proceed to attend the service they were referred to\u003c/li\u003e\n \u003cli\u003ePercentage of participants who attended T0 assessment that attend T1 assessment\u003c/li\u003e\n \u003cli\u003eReasons for non-attendance\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eReach,\u003c/p\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEngagement with referral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eLevel 1 participants: percentage meeting recommended physical activity levels at T1\u003c/li\u003e\n \u003cli\u003eLevel 2 participants: percentage attending local exercise programme at the agreed level of attendance; percentage meeting recommended levels of physical activity at T1\u003c/li\u003e\n \u003cli\u003eLevel 3 participants: proportion of physiotherapy sessions attended per participant; percentage meeting recommended levels of activity at T1\u003c/li\u003e\n \u003cli\u003ePercentage meeting recommended levels of activity on weekly basis, as per weekly diary\u003c/li\u003e\n \u003cli\u003eChange in activity levels from T0 \u0026ndash; T1\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eEffectiveness,\u003c/p\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReferral outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eTime from assessment to referral being sent\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePercentage of referrals accepted at initial site\u003c/li\u003e\n \u003cli\u003eTime from referral sent to initial appointment\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTriage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePercentage of people triaged to each level\u003c/li\u003e\n \u003cli\u003ePercentage triaged to another level after initial triage and why\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSafety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eNumber and nature of adverse events occurring in assessment process\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQualitative feasibility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.0728476821192%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eFeasibility data gathered from semi-structured interviews with participants\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003eReach,\u003c/p\u003e\n \u003cp\u003eEffectiveness,\u003c/p\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eRE-AIM: Reach, Effectiveness, Adoption, Implementation, Maintenance\u003c/p\u003e\n\u003ch4\u003eSocio-demographic Data and Medical History\u003c/h4\u003e\n\u003cp\u003eAt T0, patient demographics, medical history including cancer history and socio-economic data including equality, diversity, and inclusion (EDI) data will be collected using a standardised case report form. EDI data will be collected to meet American Society of Clinical Oncology guidance that research stakeholders should collect and publish aggregate data on diversity of trial participants [29]. The EDI data collection template was developed in line with European Union Equality data collection guidelines [30], in consultation with an external academic EDI specialist.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eSecondary\u0026nbsp;Outcomes\u003c/h3\u003e\n\u003cp\u003eThe assessment battery is presented in Table 4. Assessments will be performed at baseline (T0) and after 12-weeks (T1). The battery consists of secondary outcomes and two additional (ECOG-PS and TUG) which are used to complete the triage and referral system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eSecondary outcomes of implementation study\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eT0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eT1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"87.43801652892562%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssessment of Physical Functioning\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical activity levels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eInternational Physical Activity Questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eExercise diaries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eHealth Behaviour and Stages of Change Questionnaire\u003c/p\u003e\n \u003cp\u003eAssessment questions\u0026nbsp;[5]*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-Efficacy for Exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-Efficacy for Exercise Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-reported function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003ePatient-specific functional scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eMuscle strength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eHand Grip Strength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eFunctional lower body strength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003e30-second Sit-to-Stand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eAerobic Capacity and Endurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eSix Minute Walk Test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eAnthropometrics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eHeight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eWeight\u003c/p\u003e\n \u003cp\u003eBody Mass Index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eNutritional risk screening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eMini Nutritional Assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"87.43801652892562%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssessment of Psychosocial Concerns\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eQuality of Life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eEuropean Organisation for Research and Treatment of Cancer Quality of Life Questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eMultidimensional Fatigue Inventory\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eAnxiety and depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eHospital Anxiety and Depression Scale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTriage assessment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical activity levels\u003c/p\u003e\n \u003cp\u003eComorbidity status\u003c/p\u003e\n \u003cp\u003eFalls risk\u003c/p\u003e\n \u003cp\u003eFunctional status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eAssessment questions\u0026nbsp;[5]*\u003c/p\u003e\n \u003cp\u003eNational Comprehensive Cancer Network triage approach\u003c/p\u003e\n \u003cp\u003eTimed-Up and Go\u003c/p\u003e\n \u003cp\u003eEastern Cooperative Oncology Group- Performance Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eQualitative assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eSemi\u0026ndash;structured interviews (focus groups or 1:1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.72727272727273%\" valign=\"top\"\u003e\n \u003cp\u003eEngagement with referral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.710743801652896%\" valign=\"top\"\u003e\n \u003cp\u003eExercise diary; T1 assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2809917355371905%\" valign=\"top\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Subjective questions regarding physical activity levels are used both as a secondary outcome, and to inform the triage and referral system\u003c/p\u003e\n\u003ch4\u003ePhysical Activity and Motivation to Exercise\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003ePhysical activity at T0 and T1 will be assessed using the self-administered International Physical Activity Questionnaire (IPAQ)\u0026nbsp;[31]. The IPAQ (short-form) consists of 7 questions capturing activity levels during the previous 7 days. Data is processed using a standardised scoring protocol. Readiness to change will be assessed at T0 using the Health Behaviour and States of Change Questionnaire, which is underpinned by the Transtheoretical model\u0026nbsp;[32]\u0026nbsp;enabling categorisation of patients into precontemplation, contemplation and actions stages of change.\u0026nbsp;Self-efficacy for exercise, i.e. the extent to which a person believes\u0026nbsp;in their ability to execute an exercise plan\u0026nbsp;[33],\u0026nbsp;will be measured using the Self-Efficacy for Exercise Scale\u0026nbsp;[33, 34]. This self-report scale consists of 9 statements describing adverse circumstances for exercise (e.g. \u0026apos;The weather was bothering you\u0026rsquo;) against which the user must rank their level of confidence from 0-10 that they would exercise three times per week for 20 minutes under that circumstance.\u003c/p\u003e\n\u003cp\u003eLevels of physical activity will also be captured through asking the two physical activity questions, described above, and through completion of a weekly exercise diary which is tailored for each triage level. Participants assigned to Level 1 will record their weekly aerobic and strength exercise participation. Participants assigned to Level 2 will record their weekly attendance at their local exercise facility and any additional exercise completed. Participants assigned to Level 3 will record physiotherapy sessions attended and the physical activity recommendations given by their physiotherapist.\u0026nbsp;The weekly diary also contains contact details for the PERCS research team, information on exercise after cancer treatment and practical and safety advice for those aiming to increase their activity levels. Adherence will also be explored in semi-structured interviews and through discussion with participants at T1 assessment.\u003c/p\u003e\n\u003ch4\u003eHand Grip\u0026nbsp;Strength\u0026nbsp;and\u0026nbsp;Functional\u0026nbsp;Lower Body Strength\u003c/h4\u003e\n\u003cp\u003eHand grip strength, which provides a measure of hand and forearm strength and correlates well with overall muscle strength and physical function\u0026nbsp;[35], \u0026nbsp;will be measured by calibrated handheld dynamometry from a standard seated position with elbows at 90 degrees. Measurements will be taken in triplicate and the highest value recorded for data entry. Leg strength and endurance will be measured using the 30-second sit to stand test. The number of stands a person can complete from a standardised-height chair in 30 seconds without using arms for assistance will be recorded.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eSelf-reported\u0026nbsp;Function\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eThe patient-specific functional score is a self-report outcome measure of function[36]. Participants will identify up to three important activities which they are having difficulties performing, and then rate their current ability to do each activity from 0 (unable to perform) to 10 (able to perform at the same level as before illness).\u003c/p\u003e\n\u003ch4\u003eAnthropometric\u0026nbsp;Measures\u003c/h4\u003e\n\u003cp\u003eWeight (kilogrammes (kg)) and height (centimetres (cm)) will be recorded by standard methods using a calibrated scales and stadiometer. Body mass index (BMI) will be calculated as weight (kg)/ height (metres (m\u003csup\u003e2\u003c/sup\u003e)).\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eAerobic\u0026nbsp;Capacity\u0026nbsp;and Endurance\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eAerobic capacity and endurance will be measured using the six-minute walk test,\u0026nbsp;administered according to the American Thoracic Society Guidelines\u0026nbsp;[37]. Participants will walk for 6 minutes along a 30m walkway in a hospital corridor with the aim of achieving the furthest distance possible.\u003c/p\u003e\n\u003ch4\u003eNutritional Risk Screening\u003c/h4\u003e\n\u003cp\u003eThe Mini-Nutritional Assessment (MNA) is a validated nutritional screening and assessment tool that can identify malnutrition and risk of malnutrition in older populations. The MNA consists of 6 questions which can be summed to distinguish between elderly patients with: 1) adequate nutritional status, MNA \u0026gt; or = 24; 2) protein-calorie malnutrition, MNA \u0026lt; 17; 3) at risk of malnutrition, MNA between 17 and 23.5.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAssessment of Psychosocial Concerns:\u0026nbsp;\u003c/h3\u003e\n\u003ch4\u003eQuality\u0026nbsp;of life\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eHealth-related QOL will be measured by the European Organisation for Research and Treatment of Cancer Quality of Life\u0026nbsp;Questionnaire (EORTC- QLQ-C30)[38]. QOL categories include functional scales (physical, role, cognitive, emotional, social), symptom scales (fatigue, pain, and nausea and vomiting), global health status and QOL scale, in addition to several single-item symptom measures.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eFatigue\u003c/h4\u003e\n\u003cp\u003eFatigue will be measured using the Multidimensional Fatigue Inventory (MFI-20), a 20-item scale that measures the impact of fatigue in five dimensions: general, physical, cognitive, motivation and usual activities. It is scored from 1-20, with a cut-off score of \u0026ge;13 indicating severe fatigue[39].\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eAnxiety and Depression\u003c/h4\u003e\n\u003cp\u003eAnxiety and depression will be measured using the Hospital Anxiety and Depression Scale (HADS), a self-administered questionnaire and reliable instrument for detecting states of anxiety and depression in an outpatient setting (31). The HADS questionnaire has seven items each for depression and anxiety subscales. Scoring for each item ranges from zero to three, with three denoting highest anxiety or depression level. A total score of \u0026ge;8 points out of a possible 21 denotes considerable symptoms of anxiety or depression and a score \u0026ge;11 indicates a clinical case of anxiety or depression. If PERCS researchers have concerns for the psycho-social wellbeing of any participant, on the basis of these questionnaires or on other assessments findings, they will liaise with the Psycho-Oncology team in St James\u0026rsquo;s Hospital who can accept referrals or provide advice to the researchers as required.\u003c/p\u003e\n\u003ch3\u003eQualitative\u0026nbsp;Assessment\u003c/h3\u003e\n\u003cp\u003eAt T1 assessments, a purposive sample of at least 20 participants will be invited to complete semi-structured interviews to examine their perceptions of the triage and referral system on their physical and psychosocial wellbeing, satisfaction with the system and barriers and facilitators to engagement with the system. The PERCS research team will interview participants who represent all three triage levels and mixed demographics to understand a breadth of participant experiences. The interview guide was developed using the Consolidated Framework for Implementation Research (CFIR) [40]. CFIR is an implementation framework consists of 37 constructs which are associated with successful implementation. By analysing an intervention against these constructs, the researcher can better understand the reasons why implementation was or was not successful [41] . CFIR constructs are clustered under five domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. PERCS researchers used the online CFIR interview guide development tool (https://cfirguide.org/guide/app/#/) to build a customised interview guide based on the CFIR constructs that are the focus of this implementation evaluation. Table 5 outlines the interview guide mapped against CFIR domains. No PERCS interview questions are mapped against the \u0026lsquo;process of implementation\u0026rsquo; domain, as the four constructs in this domain (\u0026lsquo;planning\u0026rsquo;, \u0026lsquo;engaging\u0026rsquo;, \u0026lsquo;executing\u0026rsquo;, \u0026lsquo;reflecting and evaluating\u0026rsquo;) are targeted to non-participant/user stakeholders, e.g. implementation leaders and opinion leaders. \u0026nbsp;Interviews will be digitally audio-recorded and transcribed verbatim. Interview data will then be deductively analysed using pre-identified codes related to CFIR constructs, while also allowing for identification of new codes from the dataset [42, 43].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e Semi-structured interview guide, mapped against Consolidated Framework for Implementation Research (CFIR) \u0026nbsp;domains and constructs\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCFIR domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.1561461794019934%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCIFR construct\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.56810631229236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterview question*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.27574750830565%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.1561461794019934%\" valign=\"top\"\u003e\n \u003cp\u003eEvidence Strength \u0026amp; Quality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.56810631229236%\" valign=\"top\"\u003e\n \u003cp\u003eWhat are your overall thoughts about the PERCS system?\u003c/p\u003e\n \u003cp\u003eWhat did you like/not like about PERCS?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8152610441767068%\" valign=\"top\"\u003e\n \u003cp\u003eRelative Advantage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"96.18473895582329%\" valign=\"top\"\u003e\n \u003cp\u003eAre you aware of other systems/services which support people to become more active after cancer?\u003c/p\u003e\n \u003cp\u003eIf so, can you please describe the system/service and what you think are its advantages?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8152610441767068%\" valign=\"top\"\u003e\n \u003cp\u003eDesign Quality \u0026amp; Packaging\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"96.18473895582329%\" valign=\"top\"\u003e\n \u003cp\u003eWhat are your thoughts on the quality of the written materials used in PERCS (PIL, diary)? Are there any changes you would recommend to these materials?\u003c/p\u003e\n \u003cp\u003eDid you visit the PERCS webpage? \u0026nbsp;If so, what are your thoughts on it? What did you find helpful / not helpful? Are there any changes you would recommend?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8152610441767068%\" valign=\"top\"\u003e\n \u003cp\u003eCost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"96.18473895582329%\" valign=\"top\"\u003e\n \u003cp\u003eDid it cost you anything (financially) to take part in PERCS? If so, can you describe the costs?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.27574750830565%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOuter Setting\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.1561461794019934%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003ePatient Needs \u0026amp; Resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.56810631229236%\" valign=\"top\"\u003e\n \u003cp\u003ePlease describe your overall experience of the PERCS service. \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDo you feel that the PERCS system and the PERCS team understand the needs and preferences of people who have had cancer treatment? Can you explain why?\u003c/p\u003e\n \u003cp\u003eDo you think the PERCS system successfully meets the needs of people who have had cancer treatment? How?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003eIn general, how do you think people who have had cancer would respond to the PERCS system?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003eCan you think of any reason or situation where someone would find it difficult to take part in the PERCS system? \u0026nbsp;Is there any way we can make it easier for people to attend?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.27574750830565%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInner Setting\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.1561461794019934%\" valign=\"top\"\u003e\n \u003cp\u003eImplementation Climate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.56810631229236%\" valign=\"top\"\u003e\n \u003cp\u003eDo you think a system such as PERCS system is needed for people after cancer? Why/why not?\u003c/p\u003e\n \u003cp\u003eWhat did your family / partner / friends think of the PERCS system?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8152610441767068%\" valign=\"top\"\u003e\n \u003cp\u003eTension for Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"96.18473895582329%\" valign=\"top\"\u003e\n \u003cp\u003eAre you aware of other systems/services which support people to become more active after cancer?\u003c/p\u003e\n \u003cp\u003eIf so, please describe. How do you think the other systems/services meet the needs of people after cancer?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.27574750830565%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics of Individuals\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.1561461794019934%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.56810631229236%\" valign=\"top\"\u003e\n \u003cp\u003eBefore you attended your first assessment, how confident did you feel that you would be able to use the PERCS system? Why did you feel this way?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8152610441767068%\" valign=\"top\"\u003e\n \u003cp\u003eIndividual State of Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"96.18473895582329%\" valign=\"top\"\u003e\n \u003cp\u003eData obtained from Health Behaviour and Stages of Change Questionnaire at T0 \u0026amp; T1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Order of questions in table relates to their relationship to CIFR dimensions; questions will be asked in an intuitive order at interview. CFIR: Consolidated Framework for Implementation Research, PERCS: Personalised Exercise Rehabilitation in Cancer Survivorship\u003c/p\u003e\n\u003ch2\u003eData management and analysis\u003c/h2\u003e\n\u003cp\u003eA data management plan will outline how research data will be handled during and after the project. The data management plan is a live document and will be reviewed regularly throughout the study. Source documents for this study will include hospital records and the study\u0026rsquo;s data collection forms. Outcome assessments will be legibly and accurately recorded in a paper-based case report form, which will be stored in a locked, secure location only accessible by PERCS researchers. Data from the case report form will then be entered into a password protected computer data repository. All participants will be allocated a unique study code. The key to the study code will be stored securely and separately to other study data. Electronic records will be stored on password protected encrypted devices. Upon completion of the study an anonymised data set will be deposited on a secure online repository in line with open access publication requirements. Direct access will be granted to authorised representatives from the host institution, CRF and regulatory authorised to permit study-related monitoring, audits, and inspections.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA descriptive analysis will be completed for relevant implementation outcomes. Summary statistics for continuous variables and categorical variables will be presented, with sub-group analysis as appropriate. Change in physical functioning and psychosocial outcomes from T0-T1 will be analysed used paired sample t-tests or the Wilcoxon test. Qualitative data will be deductively analysed using NVivo 11 (QSR International, Australia) qualitative data analysis software.\u003c/p\u003e\n\u003ch2\u003eTrial management and governance\u003c/h2\u003e\n\u003cp\u003eManagement of the PERCS study is overseen by a trial management group who meet biannually as standard and more frequently in response to the needs of the study. The purpose of the trial management group is to: guide study conception and development of the study protocol; review and approve protocol amendments; advise on the methodology and review any relevant new information regarding the intervention or clinical area which may impact on the running of the trial; oversee the day-to-day running of the PERCS study; and ensure that the viewpoints of all stakeholder groups are considered. Membership of the trial management group includes the principal investigator, the clinical lead, the project manager, representatives from academic and clinical physiotherapy and psycho-oncology, and three patient representatives.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eDissemination\u003c/h2\u003e\n\u003cp\u003eFindings of PERCS will be disseminated via peer-reviewed publications and conference presentations. Aggregate study results will be presented to participants and their families at an education symposium upon study completion. Anonymised data will be made available on an open access repository.\u003c/p\u003e\n\u003ch2\u003ePublic and Patient Involvement\u003c/h2\u003e\n\u003cp\u003eThree individuals from the Trinity St James\u0026rsquo;s Cancer Institute Patient Representative Group sit on the trial management group and provide input into all aspects of the study. Patient representatives were extensively involved in the co-design of the PERCS website (www.cancerrehabilitation.ie), which will be available to all participants in this current study as an additional informational resource. Through an iterative process, based in user-centred design principles, patient representatives from a range of demographic and cancer-type backgrounds guided the development of this site. The patient needs identified in this co-design process also informed the execution of this current study, e.g. the need to provide user-friendly, easy-to-read written materials (participant information leaflets, exercise diaries).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study will investigate the real-world application of an exercise rehabilitation triage and referral system in cancer survivorship. The importance of triage and referral systems to support implementation of exercise rehabilitation into practice cannot be overstated. Appropriately triaging cancer survivors to the correct level of care for their needs is widely regarded as the basis of an efficient, effective stepped model of rehabilitation care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile the PERCS triage and referral system is being pilot tested on a cohort of patients treated during the COVID-19 pandemic, the system has the potential to be applied at various point across the survivorship trajectory, and with numerous sub-populations of cancer survivors. The population and context of use will largely influence the outcomes of the triage system. For example, if applied during or soon after treatment, there would be more demand on \u0026lsquo;level 3\u0026rsquo; services i.e. exercise rehabilitation with specialist healthcare professionals, as there will likely be a higher level of need in this group than in the cohort involved in this study, many of whom will be 2 years post-treatment. Other potential applications of this system include its use in people with specific cancer types, and application by other healthcare professionals, for example within a nursing-led clinic.\u003c/p\u003e \u003cp\u003eThis study is based upon a strong evidence base showing that exercise is beneficial for both the physical and psycho-social wellbeing of cancer survivors[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Physical and psycho-social outcomes will be completed for all participants, allowing us to identify a more holistic impact of exercise in this sample. Participants will have the opportunity to set targeted, meaningful goals within the clinic. This important health behaviour change technique can support engagement in physical activity [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and, supplemented by use of the Patient Specific Functional Scale, can also show change in function or ability over time [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The physiotherapy-led clinic setting further supports the holistic management of cancer survivors, as referrals can be made to other members of the oncology multi-disciplinary team, addressing the wider needs of participants as needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eExercise rehabilitation triage and referral systems are widely recommended to support people living with and after cancer to become more active and to improve physical and psychosocial wellbeing. To support implementation in clinical settings, real-world evaluation of these systems are needed. The PERCS triage and referral system supports decision making in exercise rehabilitation referrals and could help address issues of under-resourced specialist rehabilitation services, directing patients to best level of support for their need. The PERCS triage and referral system could be applied in a wide range of contexts and this study will explore its application in a physiotherapy-led clinic with people who were diagnosed with cancer during the COVID-19 pandemic.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACSM: American College of Sports Medicine; BMI: Body Mass Index; Carer: Cancer Rehabilitation to Recreation; CFIR: Consolidated Framework for Implementation Research; CRF: Clinical Research Facility; ECOG-PS: Eastern Cooperative Oncology Group-Performance Status; EDI: Equality, Diversity, Inclusion; EORTC- QLQ-C30: European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire; EXCEEDS: Exercise in Cancer Evaluation and Decision Support; HRB: Health Research Board; IPAQ: International Physical Activity Questionnaire; MFI-20: Multidimensional Fatigue Inventory; MNA: Mini-Nutirional Assessment; NCCN: National Comprehensive Cancer Network; PERCS: Personalised Exercise Rehabilitation in Cancer Survivorship; QOL: quality of life; RE-AIM: Reach, Effectiveness, Adoption, Implementation, Maintenance.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the assistance and support of the Wellcome/HRB Clinical Research Facility at St. James\u0026rsquo; Hospital, Dublin. Thank you to all the patient representatives who provide expert insights and support across all stages of the PERCS study. Thank you to colleauges in the academic and healthcare settings, and to members of the PERCS Trial Management Group, for your support with developing the protocol and overseeing the study: Prof Deirdre Connolly, Dr Amy Dennett, Dr Suzanne Doyle, Cathy Enright, Robin Menzies, Sarah Wade, Niamh Murphy, Brendan Nagle, Dr Maria Pertl and Prof Suzanne Guerin.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEG, GS, LB, JH, LON, CLD, PB and SC developed the study concept and protocol. LB and EG will oversee the implementation of the protocol, data collection and data analysis. All authors will contribute to interpretation of data. EG and LB drafted the manuscript, all authors contributed to revisions and all authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work is funded by the Irish Cancer Society in partnership with the National Cancer Control Programme through the Research Grant COV21GUI. The funders have no direct role in the design, conduct or analysis of the project.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Principal Investigator will ensure that the study is conducted in accordance with the ethical principles that have their origins in the Declaration of Helsinki. This study will be conducted in accordance with Good Clinical Practice (GCP), as defined by the International Conference on Harmonisation (ICH) and in accordance with the ethical principles underlying European Union Directive 2001/20/EC and 2005/28 EC. Ethical approval has been granted by the Tallaght University Hospital/St James\u0026rsquo;s Hospital Research Ethics Committee. All participants are required to provide written informed consent. The research ethics committee will be informed of any modifications to the study protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Emer Guinan is a member of the editorial board (Associate Editor) of this journal. Other authors have no competing interests to disclose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDepartment of Surgery, School of Medicine, Trinity College Dublin, Ireland\u003c/li\u003e\n \u003cli\u003eTrinity St James\u0026rsquo;s Cancer Institute, Dublin, Ireland\u003c/li\u003e\n \u003cli\u003eDepartment of Physiotherapy, St James\u0026rsquo;s Hospital, Dublin, Ireland\u003c/li\u003e\n \u003cli\u003ePsycho-Oncology Unit, St. James\u0026apos;s Hospital, Dublin, Ireland\u003c/li\u003e\n \u003cli\u003eTrinity St James\u0026apos;s Cancer Institute Patient Representative Group,\u0026nbsp;Trinity St James\u0026rsquo;s Cancer Institute, Dublin, Ireland\u003c/li\u003e\n \u003cli\u003eDepartment of Surgery, St James\u0026rsquo;s Hospital, Dublin, Ireland\u003c/li\u003e\n \u003cli\u003eDiscipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNurgali K, Jagoe RT, Abalo R: \u003cstrong\u003eEditorial: Adverse Effects of Cancer Chemotherapy: Anything New to Improve Tolerance and Reduce Sequelae?\u003c/strong\u003e \u003cem\u003eFront Pharmacol \u003c/em\u003e2018, \u003cstrong\u003e9\u003c/strong\u003e:245.\u003c/li\u003e\n\u003cli\u003eMehnert A, Scherwath A, Schirmer L, Schleimer B, Petersen C, Schulz-Kindermann F, Zander AR, Koch U: \u003cstrong\u003eThe association between neuropsychological impairment, self-perceived cognitive deficits, fatigue and health related quality of life in breast cancer survivors following standard adjuvant versus high-dose chemotherapy\u003c/strong\u003e. \u003cem\u003ePatient Educ Couns \u003c/em\u003e2007, \u003cstrong\u003e66\u003c/strong\u003e(1):108-118.\u003c/li\u003e\n\u003cli\u003eCampbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, Zucker DS, Matthews CE, Ligibel JA, Gerber LH\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eExercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable\u003c/strong\u003e. \u003cem\u003eMed Sci Sports Exerc \u003c/em\u003e2019, \u003cstrong\u003e51\u003c/strong\u003e(11):2375-2390.\u003c/li\u003e\n\u003cli\u003eHayes SC, Newton RU, Spence RR, Galvao DA: \u003cstrong\u003eThe Exercise and Sports Science Australia position statement: Exercise medicine in cancer management\u003c/strong\u003e. \u003cem\u003eJ Sci Med Sport \u003c/em\u003e2019.\u003c/li\u003e\n\u003cli\u003eSchmitz KH, Campbell AM, Stuiver MM, Pinto BM, Schwartz AL, Morris GS, Ligibel JA, Cheville A, Galv\u0026atilde;o DA, Alfano CM\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eExercise is medicine in oncology: Engaging clinicians to help patients move through cancer\u003c/strong\u003e. \u003cem\u003eCA: a cancer journal for clinicians \u003c/em\u003e2019, \u003cstrong\u003e69\u003c/strong\u003e(6):468-484.\u003c/li\u003e\n\u003cli\u003eSchmitz KH, Stout NL, Maitin-Shepard M, Campbell A, Schwartz AL, Grimmett C, Meyerhardt JA, Sokolof JM: \u003cstrong\u003eMoving through cancer: Setting the agenda to make exercise standard in oncology practice\u003c/strong\u003e. \u003cem\u003eCancer \u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eBrennan L, Sheill G, O\u0026apos;Neill L, O\u0026apos;Connor L, Smyth E, Guinan E: \u003cstrong\u003ePhysical Therapists in Oncology Settings: Experiences in Delivering Cancer Rehabilitation Services, Barriers to Care, and Service Development Needs\u003c/strong\u003e. \u003cem\u003ePhys Ther \u003c/em\u003e2022, \u003cstrong\u003e102\u003c/strong\u003e(3).\u003c/li\u003e\n\u003cli\u003eAlfano CM, Cheville AL, Mustian K: \u003cstrong\u003eDeveloping High-Quality Cancer Rehabilitation Programs: A Timely Need\u003c/strong\u003e. 2016(1548-8756 (Electronic)).\u003c/li\u003e\n\u003cli\u003eCovington KR, Marshall T, Campbell G, Williams GR, Fu JB, Kendig TD, Howe N, Alfano CM, Pergolotti M: \u003cstrong\u003eDevelopment of the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) algorithm\u003c/strong\u003e. \u003cem\u003eSupportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer \u003c/em\u003e2021, \u003cstrong\u003e29\u003c/strong\u003e(11):6469-6480.\u003c/li\u003e\n\u003cli\u003eMina DS, Sabiston CM, Au D, Fong AJ, Capozzi LC, Langelier D, Chasen M, Chiarotto J, Tomasone JR, Jones JM\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eConnecting people with cancer to physical activity and exercise programs: a pathway to create accessibility and engagement\u003c/strong\u003e. \u003cem\u003eCurr Oncol \u003c/em\u003e2018, \u003cstrong\u003e25\u003c/strong\u003e(2):149-162.\u003c/li\u003e\n\u003cli\u003eDennett AM, Peiris CL, Shields N, Taylor NF: \u003cstrong\u003eFrom Cancer Rehabilitation to Recreation: A Coordinated Approach to Increasing Physical Activity\u003c/strong\u003e. \u003cem\u003ePhys Ther \u003c/em\u003e2020, \u003cstrong\u003e100\u003c/strong\u003e(11):2049-2059.\u003c/li\u003e\n\u003cli\u003eRimmer J, Lai B: \u003cstrong\u003eFraming new pathways in transformative exercise for individuals with existing and newly acquired disability\u003c/strong\u003e. \u003cem\u003eDisabil Rehabil \u003c/em\u003e2017, \u003cstrong\u003e39\u003c/strong\u003e(2):173-180.\u003c/li\u003e\n\u003cli\u003eBarnett J, Vasileiou K, Djemil F, Brooks L, Young T: \u003cstrong\u003eUnderstanding innovators\u0026apos; experiences of barriers and facilitators in implementation and diffusion of healthcare service innovations: a qualitative study\u003c/strong\u003e. \u003cem\u003eBMC Health Serv Res \u003c/em\u003e2011, \u003cstrong\u003e11\u003c/strong\u003e:342.\u003c/li\u003e\n\u003cli\u003eMcLaughlin KH, Simon L, Friedman M, Siddiqui ZK, Ficke JR, Kantsiper ME: \u003cstrong\u003eLessons Learned From Implementing Rehabilitation at a COVID-19 Field Hospital\u003c/strong\u003e. \u003cem\u003eAm J Phys Med Rehabil \u003c/em\u003e2021, \u003cstrong\u003e100\u003c/strong\u003e(11):1027-1030.\u003c/li\u003e\n\u003cli\u003eRiebe D, Franklin BA, Thompson PD, Garber CE, Whitfield GP, Magal M, Pescatello LS: \u003cstrong\u003eUpdating ACSM\u0026apos;s Recommendations for Exercise Preparticipation Health Screening\u003c/strong\u003e. \u003cem\u003eMed Sci Sports Exerc \u003c/em\u003e2015, \u003cstrong\u003e47\u003c/strong\u003e(11):2473-2479.\u003c/li\u003e\n\u003cli\u003eDunphy C, McNeely ML: \u003cstrong\u003eGrowing the Workforce in Oncology Physical Therapy: From Entry Level to Specialist Care\u003c/strong\u003e. \u003cem\u003eRehabilitation Oncology \u003c/em\u003e2022, \u003cstrong\u003e40\u003c/strong\u003e(1):5-6.\u003c/li\u003e\n\u003cli\u003eMulcahy S, Prendergast J, Foley G, A OH, Murphy E, Guinan EM, Hussey J: \u003cstrong\u003eExercise Rehabilitation Services Provided by Physiotherapy Departments in Cancer Care in Ireland\u003c/strong\u003e. \u003cem\u003eIrish medical journal \u003c/em\u003e2018, \u003cstrong\u003e111\u003c/strong\u003e(9):818.\u003c/li\u003e\n\u003cli\u003eShipton DA, Dennett AM, Sayner AM, Tang CY: \u003cstrong\u003eA national survey of oncology physiotherapy services for cancer survivors in Australia\u003c/strong\u003e. \u003cem\u003eAsia Pac J Clin Oncol \u003c/em\u003e2022, \u003cstrong\u003e18\u003c/strong\u003e(5):e404-e413.\u003c/li\u003e\n\u003cli\u003eKennedy MA, Bayes S, Newton RU, Zissiadis Y, Spry NA, Taaffe DR, Hart NH, Galv\u0026atilde;o DA: \u003cstrong\u003eImplementation barriers to integrating exercise as medicine in oncology: an ecological scoping review\u003c/strong\u003e. \u003cem\u003eJ Cancer Surviv \u003c/em\u003e2022, \u003cstrong\u003e16\u003c/strong\u003e(4):865-881.\u003c/li\u003e\n\u003cli\u003eNekhlyudov L, Duijts S, Hudson SV, Jones JM, Keogh J, Love B, Lustberg M, Smith KC, Tevaarwerk A, Yu X\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eAddressing the needs of cancer survivors during the COVID-19 pandemic\u003c/strong\u003e. \u003cem\u003eJ Cancer Surviv \u003c/em\u003e2020, \u003cstrong\u003e14\u003c/strong\u003e(5):601-606.\u003c/li\u003e\n\u003cli\u003ePoghosyan H, Margaryan Y, Jeon S, Edelman EJ, Yu JB: \u003cstrong\u003eAssociation between social connectedness and stress or anxiety among older cancer survivors during the 2020-2021 winter surge of the COVID-19 pandemic\u003c/strong\u003e. \u003cem\u003eJournal of geriatric oncology \u003c/em\u003e2023, \u003cstrong\u003e14\u003c/strong\u003e(1):101390.\u003c/li\u003e\n\u003cli\u003eBrown M, O\u0026apos;Connor D, Murphy C, McClean M, McMeekin A, Prue G: \u003cstrong\u003eImpact of COVID-19 on an established physical activity and behaviour change support programme for cancer survivors: An exploratory survey of the Macmillan Move More service for Northern Ireland\u003c/strong\u003e. \u003cem\u003eSupportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer \u003c/em\u003e2021:1-9.\u003c/li\u003e\n\u003cli\u003eMina DS, Langelier D, Adams SC, Alibhai SMH, Chasen M, Campbell KL, Oh P, Jones JM, Chang E: \u003cstrong\u003eExercise as part of routine cancer care\u003c/strong\u003e. \u003cem\u003eLancet Oncol \u003c/em\u003e2018, \u003cstrong\u003e19\u003c/strong\u003e(9):e433-e436.\u003c/li\u003e\n\u003cli\u003eNCCN: \u003cstrong\u003eNational Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology - Survivorship\u003c/strong\u003e. 2018.\u003c/li\u003e\n\u003cli\u003ePodsiadlo D, Richardson S: \u003cstrong\u003eThe timed \u0026quot;Up \u0026amp; Go\u0026quot;: a test of basic functional mobility for frail elderly persons\u003c/strong\u003e. \u003cem\u003eJ Am Geriatr Soc \u003c/em\u003e1991, \u003cstrong\u003e39\u003c/strong\u003e(2):142-148.\u003c/li\u003e\n\u003cli\u003eAzam F, Latif MF, Farooq A, Tirmazy SH, AlShahrani S, Bashir S, Bukhari N: \u003cstrong\u003ePerformance Status Assessment by Using ECOG (Eastern Cooperative Oncology Group) Score for Cancer Patients by Oncology Healthcare Professionals\u003c/strong\u003e. \u003cem\u003eCase Rep Oncol \u003c/em\u003e2019, \u003cstrong\u003e12\u003c/strong\u003e(3):728-736.\u003c/li\u003e\n\u003cli\u003eShumway-Cook A, Brauer S, Woollacott M: \u003cstrong\u003ePredicting the probability for falls in community-dwelling older adults using the Timed Up \u0026amp; Go Test\u003c/strong\u003e. \u003cem\u003ePhys Ther \u003c/em\u003e2000, \u003cstrong\u003e80\u003c/strong\u003e(9):896-903.\u003c/li\u003e\n\u003cli\u003eGlasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, Ory MG, Estabrooks PA: \u003cstrong\u003eRE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review\u003c/strong\u003e. \u003cem\u003eFront Public Health \u003c/em\u003e2019, \u003cstrong\u003e7\u003c/strong\u003e:64.\u003c/li\u003e\n\u003cli\u003eOyer RA, Hurley P, Boehmer L, Bruinooge SS, Levit K, Barrett N, Benson A, Bernick LA, Byatt L, Charlot M\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eIncreasing Racial and Ethnic Diversity in Cancer Clinical Trials: An American Society of Clinical Oncology and Association of Community Cancer Centers Joint Research Statement\u003c/strong\u003e. \u003cem\u003eJournal of clinical oncology : official journal of the American Society of Clinical Oncology \u003c/em\u003e2022, \u003cstrong\u003e40\u003c/strong\u003e(19):2163-2171.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eEuropean Handbook on Equality Data (2016 revision) file:///C:/Users/guinane1/Downloads/european_handbook_on_equality_63B98CA7-CDBA-9BB3-903A6A3781B5F5E3_43205.pdf\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e\u003c/li\u003e\n\u003cli\u003eHagstr\u0026ouml;mer M, Oja P, Sj\u0026ouml;str\u0026ouml;m M: \u003cstrong\u003eThe International Physical Activity Questionnaire (IPAQ): a study of concurrent and construct validity\u003c/strong\u003e. \u003cem\u003ePublic Health Nutr \u003c/em\u003e2006, \u003cstrong\u003e9\u003c/strong\u003e(6):755-762.\u003c/li\u003e\n\u003cli\u003eGonzalez-Ramirez LP, De la Roca-Chiapas JM, Colunga-Rodriguez C, Preciado-Serrano ML, Daneri-Navarro A, Pedroza-Cabrera FJ, Martinez-Arriaga RJ: \u003cstrong\u003eValidation of Health Behavior and Stages of Change Questionnaire\u003c/strong\u003e. \u003cem\u003eBreast Cancer (Dove Med Press) \u003c/em\u003e2017, \u003cstrong\u003e9\u003c/strong\u003e:199-205.\u003c/li\u003e\n\u003cli\u003eWilcox S, Sharpe PA, Hutto B, Granner ML: \u003cstrong\u003ePsychometric properties of the self-efficacy for exercise questionnaire in a diverse sample of men and women\u003c/strong\u003e. \u003cem\u003eJournal of Physical Activity and Health \u003c/em\u003e2005, \u003cstrong\u003e2\u003c/strong\u003e(3):285-297.\u003c/li\u003e\n\u003cli\u003eResnick B, Jenkins LS: \u003cstrong\u003eTesting the reliability and validity of the Self-Efficacy for Exercise scale\u003c/strong\u003e. \u003cem\u003eNurs Res \u003c/em\u003e2000, \u003cstrong\u003e49\u003c/strong\u003e(3):154-159.\u003c/li\u003e\n\u003cli\u003eForrest KYZ, Williams AM, Leeds MJ, Robare JF, Bechard TJ: \u003cstrong\u003ePatterns and Correlates of Grip Strength in Older Americans\u003c/strong\u003e. \u003cem\u003eCurrent aging science \u003c/em\u003e2018, \u003cstrong\u003e11\u003c/strong\u003e(1):63-70.\u003c/li\u003e\n\u003cli\u003eStratford PW, Gill C, Westaway M, Binkley J: \u003cstrong\u003eAssessing Disability and Change on Individual Patients: A Report of a Patient Specific Measure\u003c/strong\u003e. \u003cem\u003ePhysiotherapy Canada \u003c/em\u003e1995, \u003cstrong\u003e47\u003c/strong\u003e(4):258-263.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eATS statement: guidelines for the six-minute walk test\u003c/strong\u003e. \u003cem\u003eAmerican journal of respiratory and critical care medicine \u003c/em\u003e2002, \u003cstrong\u003e166\u003c/strong\u003e(1):111-117.\u003c/li\u003e\n\u003cli\u003eAaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eThe European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology\u003c/strong\u003e. \u003cem\u003eJ Natl Cancer Inst \u003c/em\u003e1993, \u003cstrong\u003e85\u003c/strong\u003e(5):365-376.\u003c/li\u003e\n\u003cli\u003eSmets EM, Garssen B, Bonke B, De Haes JC: \u003cstrong\u003eThe Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue\u003c/strong\u003e. \u003cem\u003eJournal of psychosomatic research \u003c/em\u003e1995, \u003cstrong\u003e39\u003c/strong\u003e(3):315-325.\u003c/li\u003e\n\u003cli\u003eDamschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC: \u003cstrong\u003eFostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science\u003c/strong\u003e. \u003cem\u003eImplement Sci \u003c/em\u003e2009, \u003cstrong\u003e4\u003c/strong\u003e:50.\u003c/li\u003e\n\u003cli\u003eKing DK, Shoup JA, Raebel MA, Anderson CB, Wagner NM, Ritzwoller DP, Bender BG: \u003cstrong\u003ePlanning for Implementation Success Using RE-AIM and CFIR Frameworks: A Qualitative Study\u003c/strong\u003e. \u003cem\u003eFront Public Health \u003c/em\u003e2020, \u003cstrong\u003e8\u003c/strong\u003e:59.\u003c/li\u003e\n\u003cli\u003eNevedal AL, Reardon CM, Opra Widerquist MA, Jackson GL, Cutrona SL, White BS, Damschroder LJ: \u003cstrong\u003eRapid versus traditional qualitative analysis using the Consolidated Framework for Implementation Research (CFIR)\u003c/strong\u003e. \u003cem\u003eImplement Sci \u003c/em\u003e2021, \u003cstrong\u003e16\u003c/strong\u003e(1):67.\u003c/li\u003e\n\u003cli\u003eDamschroder LJ, Lowery JC: \u003cstrong\u003eEvaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR)\u003c/strong\u003e. \u003cem\u003eImplement Sci \u003c/em\u003e2013, \u003cstrong\u003e8\u003c/strong\u003e:51.\u003c/li\u003e\n\u003cli\u003eAgbadj\u0026eacute; TT, Elidor H, Perin MS, Adekpedjou R, L\u0026eacute;gar\u0026eacute; F: \u003cstrong\u003eTowards a taxonomy of behavior change techniques for promoting shared decision making\u003c/strong\u003e. \u003cem\u003eImplement Sci \u003c/em\u003e2020, \u003cstrong\u003e15\u003c/strong\u003e(1):67.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cancer, survivorship, rehabilitation, exercise, triage, implementation, function, psychosocial, COVID-19, physiotherapy","lastPublishedDoi":"10.21203/rs.3.rs-3178374/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3178374/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo effectively embed exercise rehabilitation in cancer survivorship care, a co-ordinated system of acute and community exercise rehabilitation services, forming a stepped model of care, is recommended. \u0026nbsp;Patients can be directed to the exercise rehabilitation service which best meets their needs through a system of assessment, triage and referral. Triage and referral systems are not yet widely applied in cancer survivorship practice and need to be evaluated in real-world contexts. The PERCS (Personalised Exercise Rehabilitation in Cancer Survivorship) study aims to evaluate the real-world application of an exercise rehabilitation triage and referral system in cancer survivors treated during the COVID-19 pandemic. Secondary aims are to evaluate change in physical and psychosocial outcomes, and to qualitatively evaluate the impact of the system and patient experiences, at three months after application of the triage and referral system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study will assess the implementation of an exercise rehabilitation triage and referral system within the context of a physiotherapy-led cancer rehabilitation clinic for cancer survivors who received cancer treatment during the COVID-19 pandemic. The PERCS triage and referral system supports decision making in exercise rehabilitation referral by recommending one of three pathways: independent physical activity; fitness professional referral; or health professional referral. Up to 100 adult cancer survivors treated during the COVID-19 pandemic who have completed treatment and have no signs of active disease will be recruited. We will assess participants’ physical and psychosocial wellbeing and evaluate whether medical clearance for exercise is needed. Participants will then be triaged to a referral pathway and an exercise recommendation will be collaboratively decided. Reassessment will be after 12 weeks. Primary outcomes are implementation-related, guided by the RE-AIM framework. Secondary outcomes include physical function, psychosocial wellbeing and physical activity levels. Qualitative analysis of semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) will provide insights on implementation and system impact.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion: \u003c/strong\u003eThe PERCS study will investigate the real-world application of a cancer rehabilitation triage and referral system. This will provide proof of concept evidence for this triage approach and important insights on the implementation of a triage system in a specialist cancer centre.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration:\u003c/strong\u003e This study is registered on ClinicalTrials.gov, registration number: NCT05615285, date registered: 14/11/2022.\u003c/p\u003e","manuscriptTitle":"Personalised Exercise Rehabilitation in Cancer Survivorship: The PERCS Triage and Referral System Study Protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-06 01:15:18","doi":"10.21203/rs.3.rs-3178374/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-14T14:35:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-07T05:51:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1a2c61d4-b032-4f46-b2dd-eaa3f25e0cb2","date":"2023-10-31T15:14:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"ec2ac88a-89b6-441e-84a3-764e1577ce79","date":"2023-10-24T03:13:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-10-11T13:15:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-10-11T04:47:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-08-31T11:35:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-08-31T11:33:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2023-07-17T14:30:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3dbb7dcc-d254-4c00-8d67-2acb2c5e47da","owner":[],"postedDate":"September 6th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-05-01T22:39:51+00:00","versionOfRecord":{"articleIdentity":"rs-3178374","link":"https://doi.org/10.1186/s12885-024-12266-x","journal":{"identity":"bmc-cancer","isVorOnly":false,"title":"BMC Cancer"},"publishedOn":"2024-04-23 22:39:51","publishedOnDateReadable":"April 23rd, 2024"},"versionCreatedAt":"2023-09-06 01:15:18","video":"","vorDoi":"10.1186/s12885-024-12266-x","vorDoiUrl":"https://doi.org/10.1186/s12885-024-12266-x","workflowStages":[]},"version":"v1","identity":"rs-3178374","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3178374","identity":"rs-3178374","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}