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PSYCHO-ONCOLOGY

Psycho-Oncology 13: 857–866 (2004)


Published online 3 March 2004 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.802

PREDICTORS OF ADHERENCE AND


CONTAMINATION IN A RANDOMIZED TRIAL
OF EXERCISE IN COLORECTAL CANCER
SURVIVORS
KERRY S. COURNEYAa,*, CHRISTINE M. FRIEDENREICHb, H. ARTHUR QUINNEYa, ANTHONY L.A. FIELDSb,
LEE W. JONESa and ADRIAN S. FAIREYa
a
University of Alberta, Canada
b
Alberta Cancer Board, Canada

SUMMARY

The purpose of this study was to examine predictors of exercise adherence (i.e. exercise in the intervention group)
and exercise contamination (i.e. exercise in the control group) in a randomized controlled trial of home-based
exercise in colorectal cancer survivors. At baseline, 102 participants completed measures of the theory of planned
behavior, personality, past exercise, exercise stage of change, physical fitness, and medical/demographics and then
were randomly assigned in a 2:1 ratio to an exercise ðn ¼ 69Þ or control ðn ¼ 33Þ group. Exercise was monitored
weekly for 16 weeks using self-reports by telephone. Ninety-three (91%) participants completed the trial. Adherence
was 76% in the exercise group and contamination was 52% in the control group. Hierarchical stepwise regression
analyses indicated that baseline exercise stage of change (b ¼ 0:35; p ¼ 0:001), employment status (b ¼ 0:28;
p ¼ 0:010), treatment protocol (b ¼ 0:26; p ¼ 0:018), and perceived behavioral control (b ¼ 0:20; p ¼ 0:055)
explained 39.6% of the variance in exercise adherence. Intentions (b ¼ 0:36; p ¼ 0:049) and baseline exercise stage of
change (b ¼ 0:30; p ¼ 0:095) explained 29.9% of the variance in exercise contamination. These findings may have
implications for conducting clinical trials of exercise in colorectal cancer survivors and for promoting exercise to
colorectal cancer survivors outside of clinical trials. Copyright # 2004 John Wiley & Sons, Ltd.

INTRODUCTION intervention it is necessary to achieve 100%


exercise adherence and 0% exercise contamina-
tion. In practice, however, such levels of adherence
Recently, researchers have used randomized con-
and contamination are difficult to achieve.
trolled trial (RCT) methodology to test the efficacy
Exercise adherence rates in cancer survivors
of exercise interventions in cancer survivors (e.g.
have ranged from 60 to 85% for both home-based
Courneya et al., 2003a–c; Mock et al., 1997, 2001;
(e.g. Courneya et al., 2003a–b; Mock et al., 1997,
Segal et al., 2001, 2003). A critical component to
2001; Schwartz, 2000; Segal et al., 2001) and
the success of these trials is achieving high levels of
supervised (e.g. Segal et al., 2001, 2003) exercise
exercise adherence (i.e. the extent to which the
programs, with few exceptions (e.g. Courneya
intervention group performs the exercise prescrip-
tion) and low levels of exercise contamination et al., 2003c). Exercise contamination rates, on
the other hand, are rarely reported but have
(i.e. the extent to which the control group per-
ranged from 20 to 50% in home-based exercise
forms the exercise prescription) (Courneya, et al.,
2002; Pickett et al., 2002). Theoretically, to provide programs for cancer survivors (Courneya et al.,
2003a, b; Mock et al., 2001) although supervised
an optimal test of the efficacy of an exercise
exercise programs appear to have less of a problem
(Courneya et al., 2003c; Segal et al., 2003). Before
*Correspondence to: Faculty of Physical Education, University any corrective action can be taken, however, it is
of Alberta, E-424 Van Vliet Center, Edmonton, AB, Canada necessary to understand the predictors of exercise
T6G 2H9. E-mail: kerry.courneya@ualberta.ca adherence and contamination in RCTs of cancer

Received 8 August 2003


Copyright # 2004 John Wiley & Sons, Ltd. Accepted 16 January 2004
858 K.S. COURNEYA ET AL.

survivors. To date, only one study has examined of exercise adherence whereas past exercise, sex,
this question (Courneya et al., 2002). and intention would be independent predictors of
The purpose of the present study was to exercise contamination (Courneya et al., 2002).
examine the predictors of exercise adherence and
contamination from the Colorectal Cancer and
Home-Based Physical Exercise (CAN-HOPE) METHODS
trial. The CAN-HOPE trial was an RCT designed
to compare the effects of a home-based exercise
Participants
program to usual care on quality of life (QOL) and
physical fitness in recently resected colorectal
The methods of the CAN-HOPE trial have been
cancer survivors (Courneya et al., 2003a). We
presented elsewhere (Courneya et al., 2003a).
have previously reported a 76% adherence rate
Briefly, participants were 102 colorectal cancer
and a 52% contamination rate (Courneya et al.,
survivors from the Cross Cancer Institute (CCI) in
2003a). These exercise rates precluded us from Edmonton, Alberta, Canada who: (1) had surgery
providing a definitive test of the effects of exercise
for colorectal cancer within the past 3 months, (2)
in colorectal cancer survivors and, not surpris-
had recovered from surgery, (3) were able to speak
ingly, we did not find any significant differences
English, (4) passed the revised Physical Activity
between the groups using intention-to-treat ana-
Readiness Questionnaire (rPAR-Q), and (5) had
lyses. In ‘as-treated’ ancillary analyses, however,
no contraindications to exercise based on a
we found that participants who increased versus
submaximal cardiovascular fitness test (i.e. no
decreased in cardiovascular fitness over the course
major comorbid conditions that might preclude
of the intervention had improved QOL. These data
exercise). The study received ethical approval from
suggest that if exercise adherence and contamina-
the Alberta Cancer Board and the University of
tion rates are better controlled, exercise may be Alberta.
shown to be a beneficial supportive therapy for
colorectal cancer survivors.
To guide our investigation, we adopted Ajzen’s Design and procedures
(1991) theory of planned behavior (TPB) and
Costa and McCrae’s (1992) five factor model The study was a two-armed RCT. Eligible
(FFM) as our theoretical frameworks. Both participants were identified by oncologists and
models have demonstrated utility in understanding approached by research nurses who briefly ex-
exercise in cancer survivors (Courneya et al., 2001, plained the study and gave interested participants
1999; Courneya and Friedenreich, 1999; Rhodes an information package. Interested participants
and Courneya, 2003; Rhodes et al., 2001). We also then received a telephone call from the project
included traditional demographics (e.g. age, sex, director who further explained the purpose of the
marital status, education, employment status), study and scheduled consenting participants for a
medical variables (e.g. time since surgery, cancer physical fitness test. Prior to the fitness test,
site, cancer stage, treatments), past exercise, participants were randomly assigned to an exercise
exercise stage of change, and physical fitness or control group using a random-numbers table.
indicators (e.g. treadmill time, body mass index, The fitness test was conducted by a certified fitness
sum of skinfolds, and flexibility) as additional consultant (blinded to group assignment) under
predictors. Many of these variables have been the supervision of the project director (not blinded
associated with exercise behavior in the general to group assignment) who had formal training in
population (Dishman and Sallis, 1994) and with exercise oncology. After completing the fitness
exercise adherence in previous RCTs of noncancer test, the project director provided participants
populations (Martin and Sinden, 2001). in both groups feedback on their test results
Our two primary objectives were to examine and participants assigned to the exercise group
the predictors of exercise contamination (i.e. were given a fitness consultation lasting about
exercise within the control group) and exercise 30 min. The consultation included a person-
adherence (i.e. exercise within the exercise group). alized exercise prescription for the next 16 weeks
Based on previous research, we hypothesized that based on a booklet developed by the authors
sex, extraversion, and perceived behavioral control entitled ‘Guide to Physical Exercise Following a
(PBC) would be significant independent predictors Cancer Diagnosis’ (Courneya et al., 2003a).

Copyright # 2004 John Wiley & Sons, Ltd. Psycho-Oncology 13: 857–866 (2004)
PREDICTORS OF RCT EXERCISE 859

On a weekly basis, the project director made then summing the moderate and strenuous in-
telephone calls to all participants to gather tensity minutes. For past exercise, participants
information on their level of exercise for the completed the LSI at baseline in reference to
previous week and to answer any questions. The the past month. For exercise adherence and
telephone calls were brief (3–5 min) and focused on contamination, participants completed the LSI
obtaining accurate reports of exercise behavior by telephone on a weekly basis in reference to
from both groups and on solving any exercise the past week. An independent evaluation of
barriers in the exercise group. The project director this instrument reported its reliability and validity
provided encouragement to participants in the to compare favorably to nine other self-report
exercise group who were not meeting their exercise measures of exercise based on test–retest scores,
prescriptions but did not discourage participants objective activity monitors, and fitness indices
in the control group who reported exercising. (Jacobs et al., 1993).
Participants completed a QOL questionnaire and a Exercise stage of change was drawn from the
second fitness test 16 weeks later. transtheoretical model (Prochaska et al., 1994) and
assessed using a scale developed by Marcus and
Simkin (1994). Regular exercise was defined for
Intervention
participants as ‘at least 3 times per week, for at
least 20–30 min in duration, and at least a
Participants assigned to the exercise group were
moderate intensity’ and examples of moderate
prescribed a home-based, personalized exercise
intensity exercises were provided. The statement
program based on their baseline fitness test results,
that preceded the options was ‘Before being
exercise history, performance status, adjuvant
recruited to this study. . .’. The specific options
therapy, and personal preferences (Courneya
were: (1) I was not exercising and I was not
et al., 2003a, b). The focus of the program was
thinking about starting in the near future (pre-
on improving functional well-being through car-
contemplation), (2) I was not exercising but I was
diovascular and flexibility exercises. Participants
thinking about starting in the near future (con-
were allowed to choose the mode of exercise they
templation), (3) I was not exercising regularly but I
preferred (e.g. swimming, cycling) but if they had
was exercising occasionally (i.e. at least once or
no preference they were prescribed walking. The
twice per week; preparation), (4) I was exercising
goal was to have participants exercising at least 3–
regularly but had only begun to do so within the
5 times per week, for 20–30 min, at 65–75% of the
last 6 months (action), and (5) I was exercising
predicted heart rate maximum (Pate et al., 1995).
regularly and had been doing so for longer than 6
Progression towards this goal varied depending on
months (maintenance).
motivation and capability. Participants assigned to
TPB constructs were assessed before partici-
the control group were asked not to begin a
pants knew their group assignment. Consequently,
structured exercise program and were not given an
for the intention items we asked participants
exercise prescription. They were reminded, how-
to respond to the items as if they were not
ever, that after their second fitness test (in about 16
participating in the study. The three intention
weeks) they would be given an appropriate
items ða ¼ 0:85Þ were drawn from Courneya (1994)
exercise prescription.
and focused on goals and plans for exercise.
Attitude ða ¼ 0:81Þ was measured using bipolar
Measures adjective scales from Ajzen (1991) that tapped
both instrumental (e.g. useful–useless, bad–good)
Exercise was assessed by the leisure score index and affective (e.g. enjoyable–unenjoyable, boring–
(LSI) of the Godin Leisure-Time Exercise Ques- interesting) attitude. PBC ða ¼ 0:81Þ was measured
tionnaire (Godin et al., 1986; Godin and Shep- by five questions from Ajzen (1991) that tapped
hard, 1985). The LSI contains three open-ended aspects of controllability and ease/difficulty.
questions that ask about the average frequency Subjective norm ða ¼ 0:93Þ was measured by
of mild, moderate, and strenuous exercise during three items from Ajzen (1991) that tapped
free time. We modified the LSI to include average approval and support for exercise. All items were
duration of exercise in minutes. The LSI was rated on 7-point scales.
scored by multiplying the average frequency by Personality was assessed using the NEO Five
the average duration for each intensity level and Factor Inventory (NEO–FFI; Costa and McCrae,

Copyright # 2004 John Wiley & Sons, Ltd. Psycho-Oncology 13: 857–866 (2004)
860 K.S. COURNEYA ET AL.

1992). The NEO–FFI contains 60 items that group. Variables that had significant ðp50:10Þ
measure the five personality dimensions of neuro- correlations with exercise were retained for an
ticism, extraversion, openness, agreeableness, and hierarchical linear multiple regression analyses
conscientiousness. Data are available to support (HMRAs).
the construct validity, internal consistency, and We used linear as opposed to logistic regression
test–retest reliability of the NEO-FFI (Costa analysis because we view exercise behavior as a
and McCrae, 1992). Internal consistencies in the matter of degree (i.e. a continuous outcome) rather
present study were: neuroticism ða ¼ 0:85Þ, extra- than kind (i.e. a dichotomous outcome). Linear
version ða ¼ 0:66Þ, openness ða ¼ 0:66Þ, agreeable- regression analysis produces explained variances
ness ða ¼ 0:77Þ, and conscientiousness ða ¼ 0:80Þ. ðR2 Þ and standardized regression coefficients ðbÞ.
Physical fitness was assessed for cardiovascular Effect sizes for R2 can be obtained by using a
endurance, body composition, and flexibility simple formula ðR2 =ð1  R2 ÞÞ from Cohen (1992).
(Courneya et al., 2003a). Briefly, cardiovascular Values of 0.02, 0.15, and 0.35 are considered small,
endurance was assessed by the Modified Balke medium, and large effect sizes, respectively, in the
Treadmill Test, body composition was assessed by behavioral sciences (Cohen, 1992). b’s are inter-
Harpenden calipers (British Indicators LTD, preted only relative to other b’s in the regression
London) to obtain the sum of five skinfold sites equation and can be considered on a ratio level
(triceps, biceps, subscapula, suprailiac, and medial scale (e.g. a b of 0.20 is twice as large as a b of
calf), and flexibility was assessed with the sit–and– 0.10).
reach test (Baumgartner and Jackson, 1995). The HMRAs were conducted using stepwise
Demographic and medical information were regression within theoretically based blocks of
collected using self-report and medical records. variables. For each analysis, the order of the
The demographic characteristics were age, sex blocks was as follows: (1) theory of planned
(0=female; 1=male), marital status (0=not mar- behavior constructs, (2) personality, (3) past
ried; 1=married), education (six categories ran- exercise, exercise stage, and fitness, (4) medical
ging from 1=some high school to 6=completed variables, and (5) demographics. If any block
graduate school), annual family income (six of variables did not contain a significant uni-
categories ranging from 1=5$20 000 to variate predictor, that block was skipped for that
6=>$100 000 Canadian dollars), employment particular HMRA.
status (0=not employed full-time; 1=employed
full-time), and height and weight used to deter-
mine body mass index. The medical variables were
RESULTS
days since surgery, tumor site (0=rectum; 1=co-
lon), tumor stage, node stage, metastatic stage,
colostomy (0=no; 1=yes), chemotherapy (0=no; Flow of participants through the study
1=yes), radiotherapy (0=no; 1=yes), and treat-
ment protocol (0=surgery alone; 1=surgery plus Flow of participants through the trial is
chemotherapy; 2=surgery plus radiotherapy and presented elsewhere (Courneya et al., 2003a).
chemotherapy). Briefly, we recruited 35% of eligible participants.
The follow-up assessment rate was 91.2% and did
not differ between groups ðp ¼ 0:496Þ. Participants
Statistical analyses who dropped out of our study were not signifi-
cantly different from those who completed the
We first computed Pearson’s correlations be- study except that drop outs ðM ¼ 22:0  6:2Þ were
tween each of the potential predictors and exercise more neurotic [t(1 0 0)=2.2, p ¼ 0:030] than com-
adherence and contamination. Correlations of pleters ðM ¼ 16:6  7:1Þ.
0.10, 0.30, and 0.50 are considered small, medium,
and large effect sizes, respectively, in the behavior-
al sciences (Cohen, 1992). To compensate for the Baseline characteristics
smaller sample sizes in the groups (ns ¼ 62 and
31), we used alpha = 0.10 (two-tailed) which gave Table 1 presents the baseline demographic and
us sufficient power (0.80) to detect correlations of medical variables. Table 2 presents the baseline
0.30 and 0.40 or greater, respectively, for each TPB, FFM, and exercise/fitness variables. The

Copyright # 2004 John Wiley & Sons, Ltd. Psycho-Oncology 13: 857–866 (2004)
PREDICTORS OF RCT EXERCISE 861

Table 1. Baseline demographic and medical characteristics

Variable Overall ðn ¼ 93Þ Control group ðn ¼ 31Þ Exercise group ðn ¼ 62Þ p-levela

Demographic data
Age (Mean; S.D.) 60.3 (10.4) 61.1 (9.9) 59.9 (10.7) 0.601
% Male 58.1 64.5 54.8 0.373
% Married 76.3 67.7 80.6 0.167
% Completed university 38.6 46.4 35.0 0.305
% Family income > $40 000/y 61.6 53.6 65.5 0.286
% Full-time employed 30.1 32.3 29.0 0.961
Medical data
Days postsurgery (Mean; S.D.) 73.6 (29.6) 71.6 (18.1) 74.6 (34.0) 0.580
% Colon cancer 76.1 74.2 77.0 0.761
% Tumor stage 3 or 4 80.6 87.1 77.4 0.277
% Node stage 0 59.6 61.3 58.6 0.807
% Metastatic 4.5 0.0 6.9 0.135
% Surgery 100.0 100.0 100.0 0.999
% Colostomy 9.7 9.7 9.7 0.999
% Radiotherapy (RT) 20.4 16.1 22.6 0.445
% Chemotherapy (CT) 64.5 67.7 62.9 0.717
% Surgery alone 34.4 32.3 35.5 0.847
% Surgery plus CT 46.2 51.6 43.5 0.689
% Surgery plus RT and CT 19.4 16.1 21.0 0.757
a
p-level for comparison between experimental conditions using an independent t-test or chi-square test with degrees of freedom 1,
91 (two-tailed).

groups were balanced on all variables. For base- p ¼ 0:072). These four variables were then exam-
line exercise stage, we collapsed the action and ined in a stepwise HMRA entered in the following
maintenance stages for analyses because of the blocks: (1) intention, PBC, and attitude, and (2)
small number of participants in the action stage. exercise stage. Two variables entered the regres-
sion equation}intention and exercise stage}and
explained 29.9% of the variance (a large effect) in
Exercise adherence and contamination rates exercise contamination (Table 3). Independent
predictors of exercise contamination in the final
Table 2 presents the exercise adherence and equation were intention (b ¼ 0:36; p ¼ 0:049) and
contamination rates. The exercise group did not exercise stage (b ¼ 0:30; p ¼ 0:095).
perform significantly more moderate/strenuous
exercise compared to the control group in terms
of average weekly minutes of moderate/strenuous Predictors of exercise adherence in the exercise group
exercise ðp ¼ 0:383Þ. A higher percentage of
participants in the exercise group did achieve the For the exercise group ðn ¼ 62Þ, we found
minimum exercise prescription of 60 min of significant moderate-to-large correlations between
moderate/strenuous exercise per week ðp ¼ 0:027Þ exercise adherence and exercise stage (r ¼ 0:43;
but not the optimum exercise prescription of p50:001), tumor stage (r ¼ 0:36; p ¼ 0:004),
150 min of moderate/strenuous exercise per week treatment protocol (r ¼ 0:37; p ¼ 0:003), em-
ðp ¼ 0:372Þ. ployment status (r ¼ 0:35; p ¼ 0:005), che-
motherapy (r ¼ 0:33; p ¼ 0:009), radiotherapy
(r ¼ 0:28; p ¼ 0:028), PBC (r ¼ 0:26, p ¼ 0:039),
Predictors of exercise contamination age (r ¼ 0:26; p ¼ 0:044), and intention (r ¼ 0:22,
p ¼ 0:080). These nine variables were then
For the control group ðn ¼ 31Þ, we found examined in a stepwise HMRA entered in the
significant moderate-to-large correlations between following blocks: (1) intention and PBC, (2)
exercise contamination and intention (r ¼ 0:47; exercise stage, (3) tumor stage, chemotherapy,
p ¼ 0:007), exercise stage (r ¼ 0:44; p ¼ 0:031), radiotherapy, and treatment protocol, and (4) age
attitude (r ¼ 0:35; p ¼ 0:054), and PBC (r ¼ 0:33; and employment status. Four variables entered the

Copyright # 2004 John Wiley & Sons, Ltd. Psycho-Oncology 13: 857–866 (2004)
862 K.S. COURNEYA ET AL.

Table 2. Descriptive statistics for the theory of planned behavior, personality, past exercise/fitness, and RCT exercise overall and
by experimental group

Overall ðN ¼ 93Þ Control ðN ¼ 31Þ Exercise ðN ¼ 62Þ p-levela


M (S.D.) M (S.D.) M (S.D.)

Planned behavior
Intention 5.5 (1.4) 5.5 (1.5) 5.4 (1.4) 0.799
Perceived control 5.6 (0.9) 5.7 (1.0) 5.5 (0.9) 0.320
Attitude 5.9 (0.7) 5.9 (0.8) 5.9 (0.6) 0.697
Subjective norm 6.5 (0.7) 6.5 (0.7) 6.5 (0.8) 0.921

Personality
Neuroticism 16.6 (7.1) 18.1 (6.5) 15.8 (7.4) 0.141
Extraversion 28.0 (5.0) 28.5 (5.3) 27.8 (4.8) 0.534
Openness 25.6 (5.5) 25.6 (5.6) 25.5 (5.6) 0.940
Agreeableness 32.3 (5.8) 32.3 (6.0) 32.4 (5.7) 0.950
Conscientiousness 34.8 (5.3) 35.7 (4.2) 34.3 (5.8) 0.248

Past exercise/fitness
Average minutes 93.2 (140.8) 96.6 (126.4) 91.5 (148.4) 0.869
%>60 min 40.9 41.9 40.3 0.883
%>150 min 29.0 32.3 27.4 0.632
Treadmill time 363.9 (286.3) 318.7 (267.1) 386.5 (295.0) 0.284
Sum of skinfolds 89.5 (36.7) 87.3 (43.0) 90.5 (33.5) 0.697
Body mass index 27.7 (5.3) 27.7 (5.1) 27.7 (5.5) 0.942
Flexibility 19.5 (10.4) 20.5 (11.0) 18.9 (10.1) 0.493
Exercise stage 0.615
%Precontemplation 11.8 9.7 12.9
%Contemplation 22.6 29.0 19.4
%Preparation 24.7 16.1 29.0
%Action 5.4 6.5 4.8
%Maintenance 35.5 38.7 33.9

RCT exercise
Average minutes 141.4 (137.9) 123.6 (182.7) 150.2 (109.7) 0.383
%>60 min 67.7 (47.0) 51.6 (50.8) 75.8 (43.2) 0.027
%>150 min 38.7 (49.0) 32.3 (47.5) 41.9 (49.8) 0.372
Note. RCT=randomized controlled trial.
a
p-level for comparison between experimental conditions using an independent t-test or chi-square test with degrees of freedom 1,
91 (two-tailed).

equation}PBC, exercise stage, treatment proto- adherence and contamination, we conducted


col, and employment status}and explained 39.6% further exploratory analysis of this construct.
of the variance (a very large effect) in exercise We conducted a group (exercise versus control)
adherence (Table 4). Independent predictors of by stage (precontemplation, contemplation, pre-
exercise adherence in the final equation were: paration, and action/maintenance) analysis of
exercise stage (b ¼ 0:35; p ¼ 0:001), employment variance (ANOVA) for average weekly exercise
status (b ¼ 0:28; p ¼ 0:010), treatment protocol minutes and percentage of participants achieving
(b ¼ 0:26; p ¼ 0:018), and PBC (b ¼ 0:20; 60 exercise minutes per week (Table 5; Figure 1).
p ¼ 0:055). The group by stage interaction was not signi-
ficant for average weekly exercise minutes
Ancillary analysis of baseline exercise stage of change [Fð3; 85Þ ¼ 1:2, p ¼ 0:321] but was significant for
percentage of participants achieving 60 min per
Given the relative importance of baseline week [Fð3; 85Þ ¼ 3:5, p ¼ 0:020]. Within each
exercise stage of change in predicting exercise group, we conducted an ANOVA for average

Copyright # 2004 John Wiley & Sons, Ltd. Psycho-Oncology 13: 857–866 (2004)
PREDICTORS OF RCT EXERCISE 863

Table 3. Hierarchical stepwise regression of average weekly minutes of moderate/strenuous exercise in the control group on
selected theory of planned behavior, past exercise/fitness, medical, and demographic variables ðn ¼ 31Þ

Step/predictors R2 R2change Fchange df b1 b2

1. Intention 0.224 0.224 8.38 1,29 0.47 0.36


2. Exercise stage 0.299 0.075 2.99y 1,28 0.30y
Note: p50:05; p50:01; yp50:10; b12 = standardized regression coefficients for equations #1 through #2. df = degrees of
freedom.

Table 4. Hierarchical stepwise regression of average weekly minutes of moderate/strenuous exercise in the exercise group on
selected theory of planned behavior, past exercise/fitness, medical, and demographic variables ðn ¼ 62Þ

Step/predictors R2 R2change Fchange df b1 b2 b3 b4

1. Perceived control 0.069 0.069 4.46 1,60 0.26 0.24 0.21y 0.20y
2. Exercise stage 0.242 0.173 13.44 1,59 0.42 0.37 0.35
3. Treatment protocol 0.322 0.080 6.82 1,58 0.29 0.26
4. Employment status 0.396 0.075 7.04 1,57 0.28
Note: p50:05; p50:01; yp50:060; b14 = standardized regression coeffecients for equations #1 through #4. df = degrees of
freedom.

weekly exercise minutes and Pearson’s chi-square exercise stage, employment status, treatment pro-
analyses for percentage of participants achieving tocol, and PBC. Lastly, we found a significant
60 min/week. For the control group, we found that interaction between group assignment and baseline
contamination differed by baseline exercise stage exercise stage in predicting exercise rates.
for average weekly minutes [Fð3; 27Þ ¼ 2:9, The strengths and limitations of our study merit
p ¼ 0:052] and percentage of participants achiev- comment. The main strengths include being only
ing 60 min/week [w2 ð3; 28Þ ¼ 12:9, p ¼ 0:005]. For the second study to examine predictors of exercise
the exercise group, we found that adherence adherence and contamination in an RCT, asses-
differed by baseline exercise stage for average sing exercise on a weekly basis, providing a
weekly minutes [Fð3; 58Þ ¼ 4:5, p ¼ 0:007] and comprehensive assessment of predictors, and
percentage of participants achieving 60 min/week applying a theoretical model. The main limitations
[w2 ð3; 58Þ ¼ 13:7, p ¼ 0:003]. Lastly, we compared include using self-report exercise measures and
groups by exercise stage on average weekly having a small and unbalanced sample size in the
minutes using independent t-tests and percentage two arms. The self-reports of exercise may be
of participants achieving 60 min/week using Pear- particularly problematic because of the RCT
son’s chi-square analysis (Table 5). These analyses design (Courneya et al., 2003a). That is, partici-
showed that the groups differed in exercise rates pants in the exercise group may overreport
for participants in the contemplation and prepara- exercise because they know they are supposed to
tion stages at baseline but not for those in the be exercising whereas participants in the control
precontemplation and action/maintenance stages group may underreport exercise because they
(Table 5). know they are not supposed to be exercising.
The main finding of our trial is the importance
of baseline exercise stage in predicting exercise
DISCUSSION
adherence and contamination. Exercise stage was
the strongest predictor of adherence and the
We examined predictors of exercise adherence and second strongest predictor of contamination.
contamination from the CAN-HOPE trial (Cour- Interestingly, exercise stage interacted with group
neya et al., 2003a). Our results showed that the assignment to influence the percentage of partici-
strongest predictors of exercise contamination pants achieving >60 min of moderate-to-vigorous
were intention and exercise stage whereas the exercise per week. Moreover, exercise rates dif-
strongest predictors of exercise adherence were fered between the two arms for participants in the

Copyright # 2004 John Wiley & Sons, Ltd. Psycho-Oncology 13: 857–866 (2004)
864 K.S. COURNEYA ET AL.

Table 5. Exercise adherence and contamination by exercise stage of change at baseline

Baseline exercise stage Overall ðN ¼ 93Þ Control ðn ¼ 31Þ Exercise ðn ¼ 62Þ p-levela
M (S.D.) M (S.D.) M (S.D.)

Precontemplation ðn ¼ 11Þ
Average weekly minutes 43.9 (36.5) 14.5 (14.5) 55.0 (36.5) 0.103
%>60 min/week 18.2 00.0 25.0 0.338

Contemplation ðn ¼ 21Þ
Average weekly minutes 95.3 (72.9) 58.4 (75.8) 122.9 (59.5) 0.041
%>60 min/week 66.7 33.3 91.7 0.005

Preparation ðn ¼ 23Þ
Average weekly minutes 122.0 (116.8) 34.4 (60.2) 146.3 (118.0) 0.056
%>60 min/week 65.2 20.0 77.8 0.016

Action/maintenance ðn ¼ 38Þ
Average weekly minutes 206.8 (165.2) 220.7 (231.2) 198.6 (116.2) 0.696
%>60 min/week 84.2 85.7 83.3 0.846
a
p-level for comparison between experimental groups using an independent t-test or chi-square test (two-tailed).

100
Exercise
extend these findings by suggesting that partici-
90 Control pants in the precontemplation stage might also be
80 considered for screening out.
% >60 minutes/week

70 A second important finding in the present study


60 was that cancer treatments had a significant
50 negative effect on exercise adherence. More
40 specifically, participants in the exercise group
30 who were receiving multimodal adjuvant therapy
20
(i.e. radiotherapy plus chemotherapy) had lower
10
adherence rates than participants receiving unim-
0
PC CO PR A/M odal adjuvant therapy (i.e. chemotherapy) or no
adjuvant therapy (i.e. surgery alone). Earlier
Figure 1. Percentage of participants achieving >60 min
descriptive studies (Courneya and Friedenreich,
of moderate/vigorous exercise per week by group
assignment and baseline exercise stage. PC ¼ precon- 1997, 1999) and one previous RCT (Courneya
precontemplation; CO ¼ contemplation; PR ¼ prepara- et al., 2002) had reported that medical variables
preparation; A/M ¼ action/maintenance. were not important predictors of exercise in cancer
survivors. The reasons for these inconsistencies are
unclear but may be due to the different samples,
contemplation and preparation stages but not for different treatments, timing of the exercise (i.e.
those in the precontemplation and action/main- during versus after treatment), study design (i.e.
tenance stages. Taken together, these data suggest retrospective versus prospective), and/or the rela-
that the exercise contamination problem was tively small sample sizes which may produce
caused largely by control group participants who unstable results. Studies of mixed modality treat-
were in the action/maintenance stages at baseline ments may consider stratifying on treatment
whereas the exercise adherence problem was protocol prior to randomization and monitoring/
caused largely by exercise group participants who supporting participants in the exercise group who
were in the precontemplation stage at baseline. are receiving multimodal treatments.
Our previous results had suggested that screening A third important finding of the present study
out regular exercisers (i.e. those in the action/ was that full-time employment status was a
maintenance stages) was the best approach to significant negative predictor of exercise adher-
optimizing the adherence–contamination ratio ence. It is not uncommon for cancer survivors to
(Courneya et al., 2002). Our present findings take time off work after a diagnosis and/or during

Copyright # 2004 John Wiley & Sons, Ltd. Psycho-Oncology 13: 857–866 (2004)
PREDICTORS OF RCT EXERCISE 865

treatments, although most return to work soon suggest that exercise adherence can be predicted by
after recovery (Spelten et al., 2002). The present baseline exercise stage, employment status, treat-
data suggest that survivors who do take time off ment protocol, and PBC. Exercise contamination
work during treatment may be better able to can be predicted by intentions and baseline
adhere to supportive self-help therapies such as exercise stage. We also found a group assignment
exercise. Consequently, participants who plan to by baseline exercise stage interaction for predicting
continue working full-time during cancer treat- exercise rates. These data suggest that screening
ments may be screened out or stratified and out precontemplators as well as regular exercisers
monitored closely for their ability to adhere during (i.e. action/maintenance stages) may optimize the
an exercise trial. adherence-to-contamination ratio. Consideration
As hypothesized, differences in the utility of should also be given to screening out, stratifying,
social cognitive variables for predicting exercise or closely monitoring the exercise adherence rates
emerged based on group assignment. More speci- of participants who are working full-time and/or
fically, intention was the strongest independent receiving multimodal therapy. Lastly, participants
predictor of exercise contamination but did not with strong preexisting intentions in the control
predict exercise adherence. Conversely, PBC was group may need to be monitored closely for
an independent predictor of exercise adherence but contamination whereas participants in the exercise
not contamination. These findings are consistent group should benefit from interventions to in-
with our previous study (Courneya et al., 2002) crease PBC. The present study, and future studies
and suggest that participants assigned to the like it, will help to provide an empirical basis for
control group may continue with their original improving adherence and reducing contamination
intention and do not necessarily adopt their new in exercise RCTs with cancer survivors and may
assigned intention (i.e. not to exercise). Conver- also provide useful information for promoting
sely, participants assigned to the exercise group exercise in these populations outside of clinical
have a new and uniform intention to follow, which trials.
may allow PBC to influence behavior. These
findings have now been replicated in two indepen-
dent samples and suggest that (a) participants in ACKNOWLEDGEMENTS
the control group with strong preexisting inten-
tions may need to be monitored more closely for This study was funded by grants from the National
exercise contamination and (b) strategies to facil- Cancer Institute of Canada (NCIC) and the Alberta
itate PBC in the exercise group are warranted. Heritage Foundation for Medical Research. K.S.
The generalizability of our findings may be Courneya and C.M. Friedenreich are supported by
restricted. First, we recruited only 35% of eligible Investigator Awards from the Canadian Institutes of
participants to the trial and these individuals may Health Research (CIHR) and a Research Team Grant
from the NCIC, with funds from the Canadian Cancer
be different from the 65% that we did not recruit. Society (CCS) and the CCS/NCIC Sociobehavioral
Few exercise RCTs in cancer survivors have Cancer Research Network. The authors gratefully
reported recruitment rates but those that have acknowledge Todd Bobick, MS, Joan Whittingham,
reported them have typically recruited less than RN, Neil Eves, MS, Darren Warburton, PhD, and John
40% (Courneya et al., 2003c; Segal et al., 2001, McGavock, MS for their assistance in recruitment,
2003) with rare exceptions (Courneya et al., assessment, and data collection.
2003b). The physically demanding nature of an
exercise trial may make it less attractive to cancer
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Copyright # 2004 John Wiley & Sons, Ltd. Psycho-Oncology 13: 857–866 (2004)