Caperchione et al.

BMC Health Services Research (2023) 23:1023 BMC Health Services Research
https://doi.org/10.1186/s12913-023-10003-x

RESEARCH Open Access

Exploring the practicality and acceptability

a brief exercise communication and clinician
referral pathway in cancer care: a feasibility
study
Cristina M. Caperchione1* , Madeleine English1, Paul Sharp1, Meera R. Agar2, Jane L. Phillips2,3, Winston Liauw4,5,6,
Carole A. Harris4,5,6, Susan McCullough6 and Ruth Lilian6

Abstract
Background The majority of cancer patients and cancer care clinicians-CCCs (e.g., oncologists) believe that exercise
is an important adjunct therapy that should be embedded in standard practice. Yet, CCCs do not routinely discuss
exercise with their patients, nor do they regularly refer them to exercise professionals (e.g., exercise physiologists-
EPs). This study evaluated the feasibility and acceptability of an evidence-based approach to improving exercise
communication between CCCs and their patients, including an exercise referral pathway.
Methods Implementation and testing of the Exercise Communication and Referral Pathway (ECRP) occurred in
Sydney, Australia. The ECRP included a brief oncology-initiated communication exchange with patients, CCC exercise
referral to an EP, followed by EP-initiated telephone consultation with patients concerning tailored exercise advice.
Participant perceptions concerning the feasibility and applicability of the ECPR were evaluated. Semi-structured
interviews were conducted with CCCs (n = 3), cancer patients (n = 21), and an EP (n = 1). Inductive thematic analysis
was undertaken.
Results Analysis generated three themes: (1) Navigating the role of CCCs in the ECRP, suggesting that oncology-
initiated communication is a cue to action, however there was a lack of role clarity regarding exercise referral; (2)
Implementing Patient-Orientated Care within a Standardised Pathway, highlighting the need for tailored information
and advice for patients that reflects individual disease, socio-cultural, and environmental factors, and; (3) Taking Steps
Towards Action, revealing the need for structural (e.g., EP initiated contact with patients) and policy changes (i.e.,
changes to Medicare, direct oncologist referral) to engage patients and better integrate exercise as part of standard
care.
Conclusions Findings provide important insights into improving oncology-patient exercise communication and
developing an exercise referral pathway to increase engagement and patient reach. However, individual (e.g.,

*Correspondence:
Cristina M. Caperchione
cristina.caperchione@uts.edu.au
Full list of author information is available at the end of the article

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Caperchione et al. BMC Health Services Research (2023) 23:1023 Page 2 of 10

experience, knowledge) and contextual factors (e.g., time, resources) need consideration when implementing an
ECRP.
Trial registration This trial was prospectively registered with the Australian New Zealand Clinical
(#ACTRN12620000358943) on March 13, 2020.
Keywords Cancer and exercise, Cancer care services, Exercise referral, Oncologist-patient communication, Exercise
physiologist, Exercise professionals, Integrated clinical practice

Background CCCs (and other health professionals) to (1) discuss the

Exercise is a safe and effective intervention that may role of exercise in cancer recovery with patients; (2) rec-
counteract adverse physical and psychological effects of ommend to their patients to adhere to the exercise guide-
cancer and its treatment, including reducing pain and lines; and (3) refer their patients to a professional who
fatigue, and improving quality of life [1–4]. There is also specialises in the prescription and delivery of exercise
evidence that regular exercise may be protective against (i.e., accredited EPs or physiotherapist with experience in
cancer recurrence, cancer-specific mortality, and all- cancer care) [4]. Nonetheless, many patients are unaware
cause mortality for some types of cancer (e.g., breast, of these specialty EP services, how to access them, and
colorectal, prostate cancer) [2, 5, 6]. Despite these ben- their relevant financial support schemes. Further, CCCs
efits and the burgeoning clinical support for promoting exercise communication and referrals for their patients
exercise as a standard of cancer care [1, 7], exercise is not remains low, and thus, effective utilisation of EPs is at a
routinely discussed during clinical consultations [8–10] minimum [10]. Within Medicare (Australia’s national
and exercise professionals are not regularly integrated health funding structure) general practitioners-GPs (i.e.,
into clinical care [11, 12]. family physicians) can refer patients with complex con-
Efforts are needed to increase the proportion of peo- ditions (e.g., diabetes, cardiovascular disease, cancer,
ple with cancer who meet recommended physical activ- etc.) to a care plan, providing patients with a rebate for
ity guidelines (i.e., 150 min moderate intensity or 75 min five allied health services/sessions (e.g., EP, nutritionist,
of vigorous intensity aerobic exercise and two to three psychologist). No other health professional, including
strength training sessions per week [13]) [14, 15]. While oncologists, can establish a care plan to obtain these fully
only 17–47% (varies by tumour site) of people with can- subsidised sessions. Patients can also access EP services
cer meet recommended exercise guidelines [16–18], sur- privately without a referral, however, rebates through pri-
veys reveal the vast majority have positive perceptions of vate health insurance companies are limited.
exercise during cancer treatment [19]. Similarly, the can- This lack of awareness and poor utilisation of EP ser-
cer care workforce have favourable attitudes [8, 12, 20], vices within the Australian healthcare system, could be
and believe that exercise is an important adjunct therapy overcome by better integrating EPs and other cancer
and should be embedded as part of standard practice [7, specific exercise professionals into the cancer care team,
21, 22]. There are significant barriers to the implementa- allowing bidirectional gains in both knowledge of the
tion of exercise advice and referral as a standard of care in oncologist in exercise oncology and the EP knowledge
oncology [11, 12, 14], including insufficient time, uncer- of the particular patient diagnosis and needs. There has
tainty of what to recommend, and a lack of knowledge been a global ‘call for action’ regarding this integration
and confidence to discussing and promoting exercise [11, 23], however, little has progressed across cancer care
with patients [8, 11, 12]. Additionally, clinical settings services despite evidence for exercise as part of standard
often present unique contextual and structural barriers oncology care [23]. In response to this call to action, the
to promoting exercise related to patient flow, clinician purpose of this study was to evaluate the feasibility and
training, patient funding schemes, and resource avail- acceptability of an evidence-based approach to improv-
ability (e.g., exercise professionals, space, equipment) [11, ing exercise communication between CCCs and their
12]. Addressing these barriers requires clear processes patients, inclusive of an exercise referral pathway from
and procedures to help facilitate exercise communication clinician to EPs.
from cancer care clinicians (CCCs) and support patients
to engage in regular exercise throughout their cancer Methods
trajectory. This study employed a qualitative descriptive design [24,
In Australia, the Clinical Oncology Society of Australia 25] utilising semi-structured interviews to assess the fea-
(COSA) provides best practice guidelines for health pro- sibility and acceptability of a pragmatic Exercise Commu-
fessionals whose work encompasses cancer control and nication and Referral Pathway (ECRP) approach. Ethical
care. Exercise related guidelines from COSA encourages approval for this study was provided by University of
Caperchione et al. BMC Health Services Research (2023) 23:1023 Page 3 of 10

Technology Sydney Human Research Ethics Committee and consent form to review and return to a member of
(#ETH18-3183) and the South Eastern and South West- the research team prior to the start of the trial. CCCs
ern Sydney Local Health District Human Research Eth- who consented to participate distributed letters of invita-
ics Committees (##2019/ETH00221). Methodological tion to their patients to participate in the study. The EP
procedures and processes adhered to the Consolidated involved in this study was selected for their cancer spe-
Criteria for Reporting Qualitative Research [26] (Related cific knowledge and expertise. The research team limited
File 1). utilisation to one EP to ensure intervention consistency
and trial efficacy. Eligible patients were adults (18 + years),
Exercise communication and referral pathway approach able to speak and read English, currently receiving cancer
Building on previous research and outcomes from our treatment (any stage), and under the care of a participat-
formative evaluation [12], a pragmatic approach to exer- ing CCC. CCC’s randomly invited eligible patients to
cise communication and referral was developed in col- partake in the study, to promote a representative sample.
laboration with CCCs and cancer patients (Additional Rolling recruitment was ceased once data saturation was
File 1). CCCs were provided with an informational reached for cancer patients (n = 21), acknowledging that
resource and 3-step guide (i.e., Assess, Aware, Advise) to it was unlikely that additional interviews would yield new
engage in a brief (1–2 min) conversation about exercise information. All participants provided written informed
with their cancer patients during a regular consultation consent prior to participating in the ECRP and the inter-
or appointment. The structured conversation included view post ECRP. Participants were assigned a code upon
targeted questions about the patient’s past and current their recruitment to ensure privacy and confidentiality.
exercise (i.e., pre/post diagnosis), information about the An interview was also conducted with the community EP
health benefits of exercise specific to that patient and the (n = 1) who provided the exercise counselling to partici-
cancer they are living with, and the impact that exercise pants to explore their perspectives and experiences with
may have on treatment side-effects and long-term sur- the ECRP.
vivorship. Further, information about exercise recom-
mendations for cancer patients [4] and different types of Procedures
exercises that may be beneficial (e.g., walking, swimming, Implementation of the ECRP approach was planned
strength training) was shared with patients. CCCs were to occur over a 30-day period however, COVID-19 dis-
encouraged to tailor the conversation to their patients’ ruptions lead to this extending over a 3-month period
needs and interests with consideration to individual between May-July 2021. The ECRP trial was deemed
treatment factors (e.g., cancer type, stage, symptoms, complete after successful contact by the EP to patient
etc.). To conclude, CCCs referred patients to a designated to discuss exercise and referral options. At this time,
EP (accredited exercise physiologist with a PhD in Exer- semi-structured telephone interviews were conducted to
cise Oncology) and indicated that the EP would contact answer the research questions, (1) Is the exercise commu-
them directly to further discuss their exercise and refer- nication strategy between CCCs and their patients feasi-
ral options (i.e., Medicare rebate). Within 2 weeks of the ble to undertake within a clinical setting, and (2) Does the
appointment with their CCC, patients were contacted by exercise ECRP approach meet the needs of CCC and their
an EP via telephone. EP counselling lasted approximately patients living with cancer? A relaxed conversational for-
15–20 min and included: a brief medical and physical mat was used to initiate the interviews, where the inter-
activity history, personalised physical activity recommen- viewer provided the participant with information about
dations based on patients’ disease stage/type, preferences themselves as a way to build rapport with participants.
and interests, identification of local EP clinics and other This was followed by more specific open-ended questions
local exercise opportunities, and education regarding that explored participants’ experiences and perspectives
Medicare rebated EP sessions. regarding the feasibility (e.g., delivery, uptake, and com-
pliance) and acceptability (e.g., satisfaction, engagement,
Participants and recruitment confidence, and importance) of the ECRP approach
Participants were CCCs (e.g., oncologists) and cancer (Additional File 2). All interviews were conducted within
patients/survivors (≥ 18 years) from a public hospital in 2 weeks of completing the ECRP by a female research
Sydney, Australia. A convenience sample of CCCs (n = 3) team member (ME, BSportExerSci. (Hons), BHuman-
were recruited via email invitation and word-of-mouth Sci. and current PhD candidate) trained in qualitative
from research team members affiliated with the hospital. data collection methods. They lasted approximately
Eligible CCCs were employed as an oncologist (i.e., radio/ 30–40 min, were audio recorded using a digital SonyTM
medical/surgical) or cancer focused haematologist at the recorder (ICD-PX333), and further supported by sup-
hospital and currently seeing patients living with cancer. plementary notes taken by the interviewer (ME). Inter-
CCCs who indicated interest were sent an information views were transcribed verbatim and deidentified using
Caperchione et al. BMC Health Services Research (2023) 23:1023 Page 4 of 10

participant IDs (e.g., EP, CCC 1 or Patient 27). Partici- differences within and across the interviews to determine
pants were provided an opportunity to review their own preliminary themes. Throughout this stage of the analy-
transcript and provide further explanation, or revisions. sis process, a particular focus was placed on data source
triangulation [28] and comparing how patients, EP’s, and
Data analysis CCC’s experiences converged or diverged to develop a
Inductive thematic analysis was undertaken (using comprehensive understanding of participants’ perspec-
NVIVO 12 software), whereby patterns in the data were tives on the ECRP.
identified and described to interpret and explain what
was said in addressing the research questions [27]. A Results
coding framework was inductively developed to reflect A total of 25 interviews were conducted, involving 21 out
important ideas represented in the interviews. Exam- of the initially 37 recruited patients, 3 CCCs and the 1 EP.
ples of codes utilised include ‘Perceived role of CCC’ and Figure 1 provides an overview of participant recruitment
‘Future directions for ECRP’. Two researchers (ME, PS) and flow. Table 1 outlines participant characteristics of
independently coded one transcript to verify the consis- the patients.
tency of the framework, and resolved areas of disagree- Data analysis from interviews generated three themes
ment and refined categories. Coded data were reviewed (1) Navigating the role of Cancer Care Clinicians in the
by the lead author (CMC), examining similarities and ECRP, (2) Implementing Patient-Orientated Care within

Fig. 1 Overview of participant recruitment and flow

Caperchione et al. BMC Health Services Research (2023) 23:1023 Page 5 of 10

Table 1 Participant characteristics of cancer patients CCCs however perceived that the majority of patients
Variable Participant Total %, (N = 21) were unaware of EPs or their important role in the over-
Gender all cancer care and exercise pathways. Further, the CCCs
Male 38.1 (8) perceived that the lack of EP knowledge seemed to go
Female 61.9 (13) hand-in-hand with a sense of assumed knowledge about
Cancer Stage exercise in general.
Stage 1 14.3 (3)
Stage 2 4.8 (1) It made me laugh the number of patients who told
Stage 3 14.3 (3) me that they knew enough about exercise and they
Stage 4 19.0 (4) didn’t need to be referred on [to an EP] because they
Unknown 45.5 (10) knew it all and I can tell you at their next follow
Cancer Diagnosis* up visit they still hadn’t done any exercise. (CCC3,
Breast Cancer 45.5 (10) female).
Genitourinary Cancer 23.8 (5)
Lung Cancer 9.5 (2)
Bone Cancer 9.5 (2)
As alluded to by all CCCs, this sense of assumed knowl-
Brain Cancer 9.5 (2)
edge seemed to be quite common in many patients, and
Gastrointestinal Cancer 9.5 (2)
an influential factor in uptake of the EP referral offer.
Other 9.5 (2)
*NOTE: Some patients reported more than one cancer diagnosis Implementing patient-orientated care within a
standardised pathway
Throughout the ECRP, CCCs and the EP reported utilis-
a Standardised Pathway, and (3) Taking Steps Towards ing a patient-orientated approach to their exercise
Action. Themes are described below with illustrative conversations. Within the initial stages of the referral
quotes and also summarised in Table 2. pathway, CCCs tailored the content and timing of their
brief exercise discussion on a range of factors (e.g., type
Navigating the role of cancer care clinicians in the ECRP of cancer, symptoms, emotional state, information needs
Most patients perceived the brief exercise conversations and exercise history).
with their oncologists as an important motivator to exer-
I find in the initial consultation there’s a lot to go
cise and that it provided credibility to the referral process
through. When somebody has had 6 months of che-
itself. One patient highlighted: “It was just reinforcing
motherapy, they’re grappling with recovering from
what I had thought myself anyhow. And to hear it [exer-
their surgery and there’s a lot of discussion specifi-
cise advice] from the professional [CCC], it just makes you
cally about cancer management and radiotherapy. I
feel more comfortable with it” (Patient 27, male). Another
do talk about general lifestyles but it’s really not so
patient identified her consultation with her CCC as an
much of a priority at that appointment…I just find
effective cue to action: “If she [CCC] hadn’t have men-
those initial consultations very overwhelming for
tioned it I probably would not have gone into this [con-
most patients. (CCC2, female)
sulted with the EP]” (Patient 7, female). When asked to
elaborate on the specific role of the CCC, some patients
indicated that a CCC might be able to provide general Similarly, the EP involved in the piloting of the ECRP
exercise information (e.g., keep moving, increase walk- emphasised that taking a personalised detailed approach
ing, be as active as possible) however more specific infor- in their consultations was beneficial to the tailoring of
mation and advice (e.g. exercise prescription, inclusive of exercise recommendations:
duration, intensity etc for a cancer patient) should come
What I thought was most beneficial is to ask them
from an exercise specialist.
their medical history first, so what cancer they were
I believe everyone should be doing their own jobs. diagnosed with, what treatments they’ve had, where
She’s [CCC] not an exercise therapist, she’s an oncol- in the treatment journey they are, so I can under-
ogist, so I believe the proper way was to see the exer- stand where they are at. And then after I’ve got that
cise physiologist and, in accordance with my condi- information, I can then tailor my recommendations
tion create a program. The oncologist looks after the for them. For example, if they had breast cancer and
chemo treatment and my progress but she’s not look- they just had surgery then their upper body range
ing too much at my physical activity, it’s up to me of motion would be compromised or would be a bit
and the [exercise] physiologist. (Patient 12, male). lower so encouraging strength training and aerobic
exercise is really helpful. (EP, female)
Caperchione et al. BMC Health Services Research (2023) 23:1023 Page 6 of 10

Table 2 Theme summary

Theme Description Findings Key Questions from Interview Guides
Navigat- • Explores pa- Major Considerations Patient
ing the tient’s and CCC’s • CCC exercise conversation promoted the credibil- • Did you find the brief consultation about exercise with your
role of perceptions of ity of exercise as adjunct cancer care treatment. cancer care clinician helpful?
Cancer their initial ex- • Perceived lack of awareness of EP services and • What information about exercise were you provided with dur-
Care ercise conversa- their role in cancer care provision among patients.ing this consultation?
Clinicians tions with their Additional Considerations • Were you satisfied with the amount of information provided to
in the CCC, including • CCC exercise conversation was perceived as an you during the consultation?
ECRP the CCC’s role effective cue to action. CCC
within the overall • Perceived sense of assumed exercise knowledge • Describe how your patient/s responded to including exercise as
referral pathway. within patients part of the information you discussed during the consultation?
• How did your patient’s respond to the referral of an exercise
physiologist?
Imple- • Describes the Major Considerations Patient
menting multitude of • CCCs tailored the content and timing of their ex- • What was discussed when the exercise physiologist contacted
Patient- ways the ERCP ercise conversation based on their patient’s health you?
Orientat- pathway pro- profile and emotional state. • What was the most helpful information you received from the
ed Care motes a patient- • Patient orientated approach within the referral exercise physiologist?
within a orientated pathway was well-received by patients. CCC
Stan- approach within Additional Considerations • How did you initiate the conversation about exercise with your
dardised its design and • Personalised approach in EP consultations extend- patient/s?
Pathway implementation. ed to the tailoring of exercise recommendations • At which consultation did you first initiate the conversation
including identification and referral to appropriate about exercise?
EP clinics. EP
• Can you describe (step by step) the approach you undertook
with this trial?
• What parts of the overall consult do you think were most effec-
tive? Least effective?
Taking • Identifies how Major Considerations Patient
steps the referral • Referral pathway reduces barriers to accessing • What was the most helpful information you received from the
towards pathway aligns exercise counselling. exercise physiologist?
action with a num- • Increased patient knowledge of the Australian • What changes have you made to your exercise based on the
ber behaviour healthcare system including CDMPs sand rebated recommendations or information you were given by the exercise
change principles EP sessions. physiologist?
which may assist • Positive change in patients’ attitudes towards • Based on the consultation with your clinician and exercise
patients in taking exercise. physiologist, what are your initial thoughts about participating
steps to become Additional Considerations. in exercise at this time?
more physically • Increased self-efficacy and perceived behavioural
active. control amongst patients.
• Referral pathway prompted initiation of exercise.

She [EP] asked me my address and where I lived

Within EP consultations, the tailoring of exercise infor-
and she looked up places where I could go and she
mation also extended to identification and referral to an
said [local gym] had a good reputation and she
EP clinic outside of the study, allowing for convenient
thought that they’d do the job very well… She men-
and enjoyable exercise opportunities to be identified:
tioned another in [local gym] but then she said she
So not only was I giving them recommendations but thought [local gym] would be better for me. It was
also helping them out in finding what clinics are more useful for me and more tailored to what I want
close to them, what they’re interested in, were they as opposed to just going to a gym and hoping on a
interested in one-on-one sessions or were they inter- machine. (Patient 27, male)
ested in group sessions with other cancer patients or
survivors? So really tailoring that. (EP, female)
Taking steps towards action
This patient-orientated approach to exercise conversa- Throughout the referral pathway, stakeholders identified
tions within the referral pathway was well-received by the the incorporation of numerous behaviour change prin-
majority of patients. One patient highlighted his satisfac- ciples which influenced the perceived acceptability and
tion in regard to receiving tailored suggestions for local- feasibility of the model, including pathways for direct
ised EP clinics: referral.
Caperchione et al. BMC Health Services Research (2023) 23:1023 Page 7 of 10

It was definitely very easy for the patients because Discussion

without that [referral from CCC], patients have to Our findings support the feasibility and acceptability
go to the GP themselves and go get that referral. It’s of the proposed ECRP model as an initial approach for
that extra step which could be a barrier for a lot of improving oncology-patient exercise communication
patients because they are already so busy with what and referral pathways. Moreover, these findings also pro-
they are going through and all their treatments, vide areas of refinements, modifications and enhance-
sometimes exercise could be the last thing they want ments for further progressing the ‘next steps’ of the
to do or care about… (EP, female). ECRP model. In sum, this includes a patient-orientated
approach across all stages of the model and the incor-
In addition, the referral pathway provided opportunity to poration of established behaviour change techniques to
increase patient’s knowledge concerning the relationship support the initiation of exercise including, building self-
between exercise and cancer as well as how to seek exer- efficacy, reducing perceived barriers, emphasising health
cise support and tailored exercise services. benefits, changing attitudes and offering a cue to action.
Supported by previous research [8, 9, 14], a brief com-
The most helpful thing to me was, I would know
munication exchange between oncologists and their
what facilities I could contact for my situation if I
patients about exercise should be an essential component
needed to, that’s more useful than anything. I think
of the oncology consultation and was included as the
I’m going to have a better resource, sort of a list to
initial stage of the ECRP. Exercise communication can
go to, probably more specific and more appropri-
be delivered by any member of the oncology care team
ate than I might’ve compiled on my own. (Patient 9,
(e.g., nurse) [4] however an oncologist’s recommendation
male)
in the first instance may be particularly valuable [29, 30].
Patient participants in our study and in other literature
Patients also valued learning about the Chronic Dis- found timely exchange with CCCs can be reassuring and
ease Management Plan and rebated EP sessions offered motivational, particularly because of the level of trust
through the Medicare System, many of which had no patients have with their oncologist [14, 30]. Oncologists
prior knowledge of and most intended to use these ser- and physicians often serve as central gatekeepers in pro-
vices in the future. Notably, participants linked this newly viding health care information [31], and are recognised
developed knowledge of EP services with a sense of as highly credible sources to provide patients with accu-
empowerment and self-efficacy, and potentially perceived rate and reliable information about cancer care, including
behavioural control: “I feel more confident really that if exercise [32, 33]. Despite the importance of having a brief
I need to get further information, I can sort it out prob- exercise communication between patient and oncologist,
ably more readily now than I would’ve been able to before” our findings indicate potential friction related to patient
(Patient 9, male). and CCC perceptions of EPs and the role they play within
Many patients also explained a change in attitude the referral pathway. As part of the brief oncology-patient
towards exercise after participating in the study. Patient communication exchange, CCCs need to clearly outline
31(female) summarised, highlighting a shift in their pri- the overall referral process and each health professionals’
orities: “… I should be prioritising my health, but because responsibilities within it to enhance uptake. This should
I am a Mum and I work, other things are killing my time. involve CCC’s acknowledging their own limitations
But after speaking with the EP, it hit me, I should be doing regarding exercise prescription and explaining to patients
this [exercising regularly], I have to do this!” Some also why EPs are the most appropriate sources of information
outlined that this had already transferred into action: and support.
Patient-oriented care was a strong and consistent
What I’ve changed is my mindset. When I come
theme shared by all participants (i.e., patients, oncolo-
home from my appointment and I’m exhausted I
gist, EP) throughout this study, and is further supported
really just feel like sitting down and doing nothing
within exercise oncology research [34]. A particular
but I sort of push myself for a couple of hours more
emphasis was placed on offering tailored exercise oncol-
doing stuff to keep me active … By the time I finish
ogy advice and prescription from an EP, further high-
I’m really, really exhausted and then I sleep better.
lighting the need to move away from a ‘one size fits all’
(Patient 10, female)
mindset [35]. The EP in this study went beyond tradi-
tional tailoring, and provided information concern-
ing local exercise services/programs for cancer patients
(including free, subsidized and/or full paid programs and
services), local facilities that could accommodate (e.g.,
proper equipment, supervision, etc.) cancer patients, and
Caperchione et al. BMC Health Services Research (2023) 23:1023 Page 8 of 10

local EPs or health professional with cancer and exer- relevant patient information with a nominated EP and
cise knowledge. This level of tailoring not only provides the EP then contacted the patient. Having the EP make
patients with access to cancer specific exercise resources initial contact was well received by patients, many indi-
and services, it also provides a move towards self-man- cating that this was a crucial element in ‘getting the pro-
agement via community-based services. This transition is cess’ started. To further assist in reducing access related
essential and effective for improving exercise confidence, barriers, this EP initiated approach could be combined
self-efficacy and in turn supporting long-term lifestyle with mixed modes of service delivery (i.e., telehealth and
behaviour change [36, 37]. face to face). Specifically, telehealth appointments could
Cancer specific knowledge to tailor exercise to the be used to review patient progress and assist in exercise
complexities of each type of cancer and individual maintenance in between physical visits.
patient factors (e.g., personal, environment, and social The policy changes regarding the Medicare Care Plans
determinants) is crucial to providing the most effective, and practical changes in terms of EP access have poten-
patient-oriented care and was critical in the referral path- tial to improve the exercise communication and referral
way. Cancer is a complex and everchanging disease that pathway however, they also come with some challenges to
includes hundreds of different types, stages, treatments, health service systems. Most obvious is the funding pres-
and side effects. This level of cancer specific knowledge sures and inadequate resources that continues to plague
aided the EP in providing tailored advice which was global health systems [10, 23] and the roll-on effect this
important to patients, and as previously indicated can has on services that may be deemed to be adjunct or
have a positive impact on patient confidence and exer- supplemental, such as exercise. This is where the cul-
cise behaviour change [36, 37]. Having access to training tural shift becomes critical, ensuring that all levels of the
and education specific to exercise oncology continues to health system (i.e., organisational management, oncology
grow throughout the field [22]. In Australia, we have seen workforce, health practitioners, and patients) are com-
a further progression where tertiary (e.g., Graduate Cer- mitted to embedding exercise as part of standard care.
tificate of Exercise Medicine Oncology at Edith Cowan Integrating an EP service and an exercise facility onsite at
University) and professional (e.g., EX-MED Cancer Pro- all hospitals would be an essential step in building a cul-
fessional Development Course, https://www.exmedcan- ture where exercise counselling is viewed as a vital part of
cer.org.au/) courses are being offered to EPs interested in a cancer patient’s treatment via increased awareness and
working with people living with cancer. accessibility of services and a coordinated care approach.
The findings from this feasibility study, demonstrates This study provided rich, in-depth information from
the potential viability of the ERCP pathway, however, patients, oncologists and an EP, all of which are critical
broad policy and practical changes are warranted to players in understanding how to best integrate exercise
make the pathway feasible for real-world implementa- into standard cancer care. To our knowledge this is the
tion. In terms of policy, a systems level change to the first to test a practical exercise communication and refer-
Medicare Care Plans is essential as it currently is a bar- ral pathway in a real-world setting, exploring innovative
rier for patients, oncologist, and EPs. As identified ear- ways to better implement exercise and EPs into standard
lier, in Australia only GPs can establish and refer their care to reach more people living with cancer. Although
patients with cancer to a Medicare Care Plan, enabling the study provided rich data from both patients and clini-
them to receive five subsidised EP sessions. This current cians/practitioners, the subgroup of CCCs/practitioners
referral process does not allow an oncologist to directly was small, all were employed by the same public hospital
refer patients to an EP or exercise program. Providing (except for the EP), and were located in an urban centre.
oncologists with the capacity to provide a direct referral Thus, findings may not translate across all cancer care
to an EP and/or exercise program would not only address centres or other regions, particularly rural and remote
patient barriers, but also improves the effectiveness, effi- areas. Moreover, the CCCs were known to the research
ciency, and coordination of services within the referral team and thus may have had a more proactive perspec-
pathway enhancing the overall quality of cancer care [38]. tive regarding the project compared to other CCCs,
Our study also addressed a practical issue commonly further limiting generalisability. In addition, the lack of
reported by exercise practitioners working within the diversity in the patient cohort (i.e. nearly 50% breast can-
cancer field. In a number of referral pathways, the patient cer) and inclusion of only one EP’s perspective also limits
is tasked with accessing the EP to initiate exercise advice generalisability and transferability.
and/or access to services and programs [39, 40]. This adds Further, the purpose of this study was to explore
a further obstacle for patients, and in many instances changes to an exercise communication and referral path-
results in patients never contacting an EP or engaging way, with particular consideration of the implementation
in exercise programs/services [12]. Our study shifted process. As such, once the EP completed the initial dis-
the focus, where the oncologist (with consent) shared cussion with the patient the intended aim was reached
Caperchione et al. BMC Health Services Research (2023) 23:1023 Page 9 of 10

Data Availability
and no further data was collected. Therefore, it was not The datasets generated during and/or analysed during the current study are
possible to determine if the ECRP resulted in a change available from the corresponding author on reasonable request.
to exercise engagement or access to exercise services/
programs. Further experimental research (e.g., RCT, pre- Declarations
post trials) on a diverse (e.g., socio-geographic) sample
Ethics approval and consent to participate
is needed to examine effectiveness of ECRP at increas- This study was performed in line with the principles of the Declaration of
ing exercise. An additional limitation includes the study’s Helsinki. Ethical approval was obtained from the University of Technology
attrition rate. Approximately 40% of patients (N = 14) Sydney Human Research Ethics Committee (#ETH18-3183) and the South
Eastern and South Western Sydney Local Health District Human Research
who consulted with the EP dropped out of the research Ethics Committees (##2019/ETH00221). Informed consent was obtained from
study prior to completing their interview. As such, attri- all individual participants included in the study.
tion bias may be present within the sample. However,
Consent for publication
given the target population, it is important to note N = 3 Not Applicable.
of these participants did not complete interviews because
of death or significant illness. Competing interests
The authors declare that they have no competing interests.

Conclusions Author details

1
In sum, the piloted ECRP is highly acceptable in its’ cur- School of Sport, Exercise and Rehabilitation, University of Technology
Sydney, Sydney, NSW, Australia
rent form, with only minor improvements to the struc- 2
IMPACCT, University of Technology Sydney, Sydney, NSW, Australia
ture and processes of the model suggested. Specifically, 3
School of Nursing, Faculty of Health, Queensland University of
CCCs need to provide a more comprehensive overview Technology, Brisbane, QLD, Australia
4
Cancer Care Centre, St George Hospital, Sydney, NSW, Australia
of the referral process and the roles and responsibilities 5
St George and Sutherland Clinical School, University of New South Wales,
of all stakeholders involved in it. However, for this refer- Sydney, NSW, Australia
6
ral pathway to be more feasible in the future, a number Translational Cancer Research Network, Sydney, NSW, Australia

of practical (i.e., formal integration of CCCs and exercise

Received: 27 March 2023 / Accepted: 4 September 2023
specialists, EP initiated contact with patients) and pol-
icy changes (i.e., changes to Medicare, including direct
oncologist referral) need to occur. Collectively, these
changes may make a significant contribution to improv-
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