Hamilton Niagara Haldimand Brant LHIN, Hamilton Niagara Haldimand Brant Regional Cancer Program

McMaster Physical Activity Centre of Excellence (PACE) – MacWarriors

1. Mission 

1. To support and empower program participants and to maximize cancer survivorship through exercise.
2. At a Glance

1. Location: Hamilton, Ontario
2. Program Site: McMaster Physical Activity Centre of Excellence (PACE), McMaster University
3. Program Launch Date: February, 2015
4. Key Stakeholders in Initiation

1. Contact Information

1. Website: https://pace.mcmaster.ca/programs/mac-warriors-cancer-rehabilitation 
2. Facebook: None
3. Twitter: PACE McMaster @PACE_McMaster
4. Email: macwarriors@mcmaster.ca 
5. Phone: 905-525-9140, ext 27223
6. Fax: 905-525-7629

E. Community Partnerships and Affiliations

1. Development and History

1. 2013: Formerly known as the Centre of Health Promotion and Rehabilitation (CHPR), PACE was formalized as an exercise research and training centre with a team of researchers, health-care professionals, staff, and students devoted to studying and improving health and well-being among older adults and people with chronic disease or disability. PACE houses community-based exercise programs, including: i) MacMSFITT Exercise and Wellness Program for people living with Multiple Sclerosis, ii) MacCardiac Rehabilitation Program, which offers exercise-based rehabilitation for patients living with or at risk for coronary artery disease as well as individuals who have experienced cardiac events, interventions, and surgeries, iii) MacSeniors Exercise and Wellness Program, which offers supervised exercise sessions and balance training for individuals 55 years of age and older, and iv) the MacWheelers Exercise and Wellness Program for individuals who are living with spinal cord injuries and other neurological impairments. 
2. 2014: MacWarriors was developed in response to a gap in the types of physical activity programs offered at PACE. Staff and administration determined there was a need for a more supervised and tailored exercise program for individuals with cancer. 
3. 2015: Twelve participants were enrolled in a group-based exercise pilot program called MacWarriors. This initial pilot program was 4 weeks in duration.
4. 2015-2016: MacWarriors transitioned from a group-based exercise class to individualized exercise prescription in a group setting, in response to the diversity of exercise tolerances observed in the cancer survivor population.
5. Key Barriers to Development

1. Program awareness
   1. “Despite outreach to physicians and hospitals as well as staff participation at events in the community, promoting widespread awareness of the program continues to be a challenge.”
2. Perceived risk
   1. “Historically, cancer survivors have been advised to rest throughout treatment and recovery, not unlike cardiac patients in the first half of the twentieth century. Best evidence now recommends that people living with cancer should try to remain as physically active as their symptoms allow them to be in an effort to combat side-effects, promote health, and reduce the risk of future disease. However, the idea that exercise can be beneficial for people living with cancer does not seem to be common knowledge. As the benefits of exercise become more widely known, we think that exercise participation will improve and we hope that exercise will become an integral part of cancer care and recovery.”
3. Infrequent physician referral  
   1. “Cancer care is complex and health-care professionals are balancing multiple demands and referrals for each patient. Promoting exercise as a key component of treatment is challenging, but we hope physicians will value the established effects of exercise and invest in the program through patient referral”. 
4. Key Facilitators to Development

1. Targeted promotion
   1. “Our promotion initiatives have included: a visit and presentation at the Juravinski Cancer Centre, presence at conferences (Life after Breast Cancer conference, Canadian Society for Exercise Physiology, Americal College of Sports Medicine) and events (Bright Run), group tours, and dissemination of marketing material.”
2. Current Staff Structure

*Workshop Details: Students are provided with education on current clients, cancer types, treatment options, and medical history. Students also receive an introduction to all modes of equipment, general exercise guidelines, safe exercise techniques, and emergency action plan. 

1. Core Practices

1. Facility 
   1. Large 4,000 square foot facility

1. Parking
   1. Accessible parking available on-site at a cost ($20 per month)

1. Cost Structure
   1. Initial intake session – $100/hour
   2. Physiotherapy sessions – $65/half hour
      1. The physiotherapy appointments are billable through extended health care and operate on a pay per appointment basis.
   3. Exercise sessions – $50/per month
      1. The exercise membership can be purchased in a 6-month or 12-month block period.

1. Funding and Support
   1. Institutional support (McMaster University) 
      1. The Department of Kinesiology and Faculty of Science contributes the space (including utilities and facilities maintenance), and subsidizes on-floor student staff. (5%)
   2. Fundraising initiatives (40%)
   3. Revenue from the MacWarriors Program (55%)
      1. Covers cost of all staff (with the exception of subsidies for student staff) and equipment.

1. Participant Recruitment
   1. Referral sources
      1. Physician referral (e.g., oncologists and family physicians) (75%)
      2. Word of mouth (25%)
   2. Awareness initiatives
      1. Program participants informally distribute marketing packages, brochures, and referral forms to their physicians at the Juravinski Cancer Centre and Joseph Brant Hospital. 
      2. Booths set up to promote program at various conferences and events related to cancer care (e.g., life after breast cancer, bright run).
      3. Media (e.g., newspaper article published in Hamilton Spectator)

1. Participants
   1. Eligibility criteria: Adult individuals of any age, with any type of cancer, and any stage are eligible to participate. Physician referral is required.
   2. Participants per session: 4-15 participants
   3. Staff to participant ratio: 1:2 leader to participant ratio
   4. Total number of participants currently in program: 10
   5. Total number of program graduates: 30

1. Initial intake session
   1. Client intake sessions are performed by a physiotherapist (participants have the opportunity to be reassessed every month)
      1. Intake Assessment Measures
         1. Comprehensive medical and cancer-related history
         2. Physical function
            1. Strength (core, upper extremity, lower extremity)
            2. Range of motion
            3. Functional ability 
            4. Orthopedic injuries/concerns
         3. Review of current activity level and tolerance 

1. Program Schedule 
   1. Session duration: 1.5 hours
   2. Frequency: 2 sessions per week
   3. Length: No point of program discharge
   4. Session schedule: Tuesdays and Thursdays at 12:00pm-1:30pm
   5. Warriors Plus: Clients who are safely able to tolerate more exercise in additional to the twice weekly sessions are offered the option to attend drop-in sessions during operational hours for other PACE community programs (Monday-Friday: 8am-12pm; Tuesdays & Thursdays: 2pm-7pm; Mondays & Wednesdays: 2pm-4pm)

1. Program Design
   1. The MacWarriors program was designed to meet the Canadian Physical Activity Guidelines.
   2. Individualized exercise prescription based on medical history, functional ability, and client-stated goals
      1. Fitness components include aerobic, strength, balance, flexibility, functional and rehabilitative exercises
   3. Equipment
      1. Walking track, treadmills, stair climbers, recumbent bikes, upright bikes, arm ergometers, arc trainers, Nu-Step, step risers, weight machines, cable machines, medicine balls, floor mats, free weights, resistance tubes, stability balls, foam pads and rollers

1. Educational Components
   1. Informal education (optional): Educational elements regarding the benefits of physical activity for cancer survivors are provided by a Registered Physiotherapist, Registered Kinesiologists, ACSM-Cancer Exercise Trainer, and student program assistants.

1. Program Evaluation
   1. MacWarriors does not currently evaluate program effectiveness.
2. Current Barriers to Participation

1. Infrequent physician referral 
   1. “Cancer care is complex and health-care professionals are balancing multiple demands and referrals for each patient. Promoting exercise as a key component of treatment is challenging, but we hope physicians will value the established effects of exercise and invest in the program through patient referral”. 
2. Program schedule 
   1. “Program times are limited based on facility availability.”
3. Return to work  
   1. “As clients return to work, the timing of the program can be a barrier to long-term adherence.” 
4. Treatment-related side effects
   1. “Exercise tolerance may vary from day to day as a result of treatment. Cancer-related fatigue and pain can limit exercise participation and tolerance.”
5. Program cost
   1. “MacWarriors does not receive operational funding that would be required in order to offer a free exercise program to cancer survivors. Clients pay membership and parking fees out of pocket and may bill physiotherapy components through extended health coverage.” 
6. Transportation 
   1. “Clients have reported that transportation is a barrier as well. As an alternative to parking on campus, public buses run to the University, but the closest stop is still quite a ways from the building.”
7. Facilitators of Participation

1. Social program atmosphere
   1. “Although each person’s experience with cancer is unique, program participants bond over their shared experiences. They support each other to attend and encourage each other to get the most out of each exercise session.” 
2. Benefits of physical activity
   1. “Best evidence recommends that people living with cancer should try to remain as physically active as their symptoms allow them to be in an effort to combat side-effects of treatment, to promote both physical and psychological health, and to reduce the risk of future disease.” 
3. Location
   1. “McMaster University is central in the Hamilton-Wentworth community and it is in close proximity to hospitals of Hamilton Health Sciences. Clients attend from Dundas, Ancaster, Stoney Creek, Burlington, and other surrounding cities.”  
4. Future Directions

1. To grow the MacWarriors program through communication with physicians and community outreach. 
2. To re-examine program structure to identify barriers to program growth. 
3. To evaluate program effectiveness