Health System-level Barriers And Facilitators To Including Exercise Programs Into Routine Cancer Care In Europe

There is ample evidence of the positive impact of exercise on adverse effects of cancer treatment. Whether exercise programs become widely accessible for cancer patients depends on their costs, in addition to usual care, and on the willingness of healthcare systems to include exercise programs as part of cancer care. Even implementing interventions with abundant evidence on (cost-)effectiveness in healthcare systems is challenging. While there are patient-level barriers to and facilitators of exercise, the attitudes and beliefs of healthcare providers, policy makers and healthcare insurers can also play an important role in integrating exercise programs in cancer care. PURPOSE: To identify health system-level barriers and facilitators to including exercise programs into routine cancer care in Europe. METHODS: In total, 22 online interviews were conducted with a range of stakeholders (i.e., healthcare providers, policy makers at the hospital and national level, and healthcare insurers) in 5 European countries (NL, DE, SP, SE, PL). Main topics of the semi-structured interviews included attitudes towards, and perceived barriers for and facilitators of incorporating exercise programs into cancer care in Europe. Interviews were transcribed verbatim and coded based on a preliminary coding framework, supplemented by themes that emerged during the interviews. RESULTS: A major barrier to inclusion of exercise programs in cancer care, particularly among policy makers and healthcare insurers, is the lack of knowledge among most stakeholders about the positive exercise effects. Moreover, there is no clear consensus on who, within the healthcare system, owns the responsibility to refer patients to exercise programs or reimburse this type of supportive care. Suggestions to overcome these barriers include educating stakeholders, integrating exercise into clinical guidelines, increasing patient awareness, providing referral tools, and establishing the cost-effectiveness of exercise interventions. Inter-country differences were observed. CONCLUSION: We identified important barriers to and facilitators of integrating exercise programs into cancer care. This information is important for developing effective implementation strategies tailored to each European country's specific healthcare system. This project has received funding from the European Union's Horizon 2020 research and innovation programme (No 825677) and co-funding from the National Health and Medical Research Council of the Australian Government (ID 1170698)