Cancer is the second leading cause of death globally [1], and the prevalence of some cancer types is increasing worldwide [2]. This increase seems related to an unhealthy lifestyle, such as poor diet, lack of physical activity, overweight, sedentary behaviour, alcohol use and smoking [3, 4]. Early detection and improved treatment methods (chemotherapy, hormonal, radiation, operation) have resulted in an increased life expectancy [5]. However, surviving cancer, is often associated with a reduced quality of life and impairments in mental and physical functioning. Transdiagnostic clinical problems of cancer survivors that lead to a reduced quality of life include pain, fatigue, anxiety and depression, fear of cancer recurrence, cognitive impairments, sleep problems and problems with returning to work [6]. In the Netherlands, almost 75% of cancer survivors (with recency of onset varying between several months to several years) reported fatigue, 30–50% reported symptoms of depression and/or anxiety, and about 50% suffer from impairments in cognitive functioning [7]. Moreover, these problems reduce the patient’s ability to return to a productive work life [8, 9], while working is viewed as a sign of well-being and normality, providing structure, social contacts, and financial support [10]. Hence, there is an urgent need for aftercare programs for cancer survivors that improve overall quality of life.
So far, these problems have been addressed in a range of aftercare programs focused on a single or a few intervention components [6]. For example, exercise programs reduce cancer-related fatigue during and after treatment [11, 12] and improve workability [13]. Furthermore, dietary and / or physical activity interventions improve physical functioning and fatigue in gynaecological cancer survivors [14], but these interventions seemed ineffective in reducing overall quality of life. An interdisciplinary approach to aftercare with a focus on healthy lifestyle, including several therapeutic disciplines and intervention components seems necessary to increase overall quality of life and address the complex and personal needs of cancer patients [15].
There are several hypothesized advantages to an interdisciplinary approach. First, cognitive, affective and sleep problems require different management strategies than the often targeted pain and fatigue. This includes mind-body interventions and psycho-oncology [6]. Second, addressing multiple problems with different strategies may work synergistically. For example, fear of cancer recurrence might be more effectively targeted if psychological therapy is used to normalize it [16], and self-management is increased by addressing lifestyle changes that can reduce the patient’s actual risk of recurrence [17, 18]. In addition, according to the currently dominating network theory of mental disorders [19, 20], complex causal interactions between many of the reported clinical problems (e.g., anxiety, depression, fatigue, cognitive problems) are expected, and therefore, reductions in these problems are expected to reinforce reductions in others through positive upward spirals.
According to a recent review [15], inter- and multidisciplinary rehabilitation programs for cancer survivors have the potential to improve overall quality of life including return to work. However, these programs were conducted in addition to specialist-led follow-up or active treatment. Primary care-led programs (e.g., coordinated by the family doctor) have the potential to combine various kinds of follow-up care. Importantly, they have been shown to be equally effective, are widely applicable to many cancer survivors, and are more cost-effective than specialist-led care [21]. In line with this, the Dutch General Practitioners Association (Nederlandse Huisartsen Genootschap) recommends primary care-led interdisciplinary aftercare [22]. Therefore, the current study investigates the feasibility and effectiveness of a transdiagnostic, integrative, family doctor-led interdisciplinary aftercare program for cancer survivors, called the “Transdiagnostic Oncology Program” (TOP).
TOP is a 12-month combined lifestyle intervention, consisting of physical exercise, mind-body therapy, dietary and sleep hygiene recommendations, and depending on the person’s needs, psychological therapy (by psycho-oncologists). TOP aims at improving overall quality of life, by targeting the most common (transdiagnostic) clinical problems of cancer survivors (see Fig. 1). Beumeler et al. showed that TOP was feasible and that quality of life, among others, significantly improved within the intervention group [23]. The current study examines the feasibility and effectiveness of TOP in a larger and controlled before-and-after pilot study. It was hypothesized that TOP is feasible in the primary care setting, and leads to significant improvements in quality of life, compared to the control group. Secondary outcomes included the assessment of intermediate outcomes important for quality of life (happiness, fatigue, mental health, work ability).