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RiseTx: testing the feasibility of a web application for reducing sedentary behavior among prostate cancer… Trinh, Linda; Arbour-Nicitopoulos, Kelly P; Sabiston, Catherine M; Berry, Scott R; Loblaw, Andrew; Alibhai, Shabbir M H; Jones, Jennifer M; Faulkner, Guy E Jun 7, 2018

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SHORT PAPER Open AccessRiseTx: testing the feasibility of a webapplication for reducing sedentary behavioramong prostate cancer survivors receivingandrogen deprivation therapyLinda Trinh1*, Kelly P. Arbour-Nicitopoulos1, Catherine M. Sabiston1, Scott R. Berry2, Andrew Loblaw2,Shabbir M. H. Alibhai3, Jennifer M. Jones4 and Guy E. Faulkner5AbstractBackground: Given the high levels of sedentary time and treatment-related side effects in prostate cancer survivors(PCS), interventions targeting sedentary behavior (SED) may be more sustainable compared to physical activity (PA).Purpose: To examine the feasibility of a web-based intervention (RiseTx) for reducing SED and increasing moderate-to-vigorous physical activity (MVPA) among PCS undergoing ADT. Secondary outcomes include changes in SED, MVPA,light intensity PA, and quality of life.Methods: Forty-six PCS were recruited from two cancer centres in Toronto, Ontario, Canada between July 2015–October 2016. PCS were given an activity tracker (Jawbone), access to the RiseTx website program, and providedwith a goal of increasing walking by 3000 daily steps above baseline levels over a 12-week period. A range of supporttools were progressively released to reduce SED time (e.g., self-monitoring of steps) during the five-phase program.Objective measures of SED, MVPA, and daily steps were compared across the 12-week intervention using linear mixedmodels.Results: Of the 46 PCS enrolled in the study, 42 completed the SED intervention, representing a 9% attrition rate.Measurement completion rates were 97 and 65% at immediately post-intervention and 12-week follow-up for allmeasures, respectively. Overall adherence was 64% for total number of logins (i.e., > 3 visits each week). Samplemean age was 73.2 ± 7.3 years, mean BMI was 28.0 ± 3.0 kg/m2, mean number of months since diagnosis was 93.6 ± 71.2, and 72% had ADT administered continuously. Significant reductions of 455.4 weekly minutes of SED timewere observed at post-intervention (p = .005). Significant increases of + 44.1 for weekly minutes of MVPA was observedat immediately post-intervention (p = .010). There were significant increases in step counts of + 1535 steps from baselineto post-intervention (p < .001).Conclusions: RiseTx was successful in reducing SED and increasing MVPA in PCS. PCS were satisfied with theintervention and its components. Additional strategies may be needed though for maintenance of behaviorchange. The next step for RiseTx is to replicate these findings in a larger, randomized controlled trial that willhave the potential for reducing sedentary time among PCS.Trial registration: NCT03321149 (ClinicalTrials.gov Identifier).Keywords: Sedentary behavior, Prostate cancer, Feasibility, web-based, physical activity* Correspondence: linda.trinh@utoronto.ca1Faculty of Kinesiology and Physical Education, University of Toronto,Toronto, ON, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Trinh et al. International Journal of Behavioral Nutrition and Physical Activity (2018) 15:49 https://doi.org/10.1186/s12966-018-0686-0BackgroundAdvances in prostate cancer treatment, particularlythrough the use of androgen deprivation therapy (ADT),have contributed to the growing survival rate [1, 2]. Al-though ADT improves survival from prostate cancer, it isassociated with many adverse health effects such as de-creased strength, impaired physical function, and physicalinactivity [3]. As such, supportive care interventions areneeded to reduce the chronic and late-appearing effectsduring the transition into survivorship.Physical activity (PA) has a positive impact on clinical out-comes such as improvement in overall quality of life (QoL),cancer-specific mortality, and reducing treatment-relatedtoxicities in cancer survivors [4], including PCS [5–7].Despite these benefits of regular PA, the majority of PCSare not meeting public health PA guidelines [8–11]. Thereis also a significant decrease in PA levels during adjuvanttherapy and levels remain low post-treatment [12].Short-term supervised PA programs can improve fitnessand patient-reported outcomes in PCS [13], but PA de-clines significantly after the intervention and long-termadherence is often difficult [13–15].Therefore, alternative approaches to alleviating the bur-den of ADT among PCS are needed. Many of thesechronic health conditions may be preventable with lifestylechanges such as reduced sedentary behavior (SED) – yetthere are no known effective strategies aimed at reducingSED among men on ADT. SED is defined as any wakingbehavior characterized by a low energy expenditure (i.e.,≤1.5 resting metabolic equivalents) while in a sitting or re-clining posture [16]. The focus on SED is of practical andclinical value and may be a more feasible targeted inter-vention approach. There are no reported interventions tar-geting SED in cancer survivors. Furthermore, few studieshave examined relationships among SED, treatment sideeffects, and QoL in this population [11, 17].Targeting SED makes intuitive sense given that themajority of cancer survivors’ time is spent sedentary. In-dependent of PA, high volumes of SED are associatedwith chronic disease-related risk factors such as centraladiposity, elevated blood glucose and insulin [18]. Thesefactors may be amplified through the course of ADT[17–19]. Therefore, an important complementary focusis to reduce time spent sedentary in addition to increas-ing habitual PA.The Medical Research Council (MRC) advises a system-atic approach to intervention development, which in-cludes an iterative process of identification of the evidencebase; developing a theoretical understanding, and usingpilot work to inform final modifications to the interven-tion prior to evaluation [20]. The framework of RiseTx fol-lows this iterative process by using a two-phase feasibilitystudy where Phase 1 involved formative research to tailorthe final content and structure of the intervention, whilePhase 2 was to test the feasibility of a web-based interven-tion for decreasing SED. In Phase 1, focus groups wereconducted with PCS on ADT to address perceptions re-garding SED and preferences for a web-based SED inter-vention. Many PCS expressed that the design should beeasy to use; have an alerting function to interrupt sitting;have the ability to track and monitor PA levels; be tailoredto the individual; and involve social support [21]. Thefindings of Phase 1 informed the development of the12-week web-based SED intervention, Reducing SittingEveryday for Treatment (RiseTx), for men on ADT. Tothe best of our knowledge, this is the first intervention totarget SED in cancer survivors.Thus, the purpose of this study was to examine feasi-bility indicators such as recruitment, adherence, numberof adverse events, and acceptability of the RiseTx inter-vention in PCS on ADT. Secondary outcomes werechanges in SED, MVPA, light-intensity PA, and QoL.MethodsRecruitment and eligibility criteriaMen who were diagnosed with prostate cancer and pre-scribed ADT were recruited predominantly throughGenitourinary (GU) clinics in two large cancer centersin Toronto, Ontario, Canada between July 2015 and Oc-tober 2016. Inclusion criteria included: i) ≥ 18 years ofage; ii) men with localized or asymptomatic metastaticprimary prostate cancer (Stage I-III); iii) currently re-ceiving ADT (continuous and/or intermittent) for atleast 6 months; iv) active e-mail address to access theintervention website; v) proficient in English; vi) insuffi-ciently active (< 150 min of moderate-intensity PA/week); vii) no uncontrolled co-morbidities; and viii)medical clearance from the primary healthcare provider.The study was approved by the research ethics board.All participants provided written informed consent.Sample size calculationAn a priori sample size calculation was not conducted dueto the feasibility nature of this study [22]. A post hoc cal-culation with 46 participants revealed 90% power to detecta medium effect size of 0.30 (Cohen’s f) for our primary(i.e., feasibility) and secondary outcomes (i.e., PA, SED,QoL) using a 2-tailed test with α = 0.05 [23]. Given thatthis was a feasibility study with a small sample size, the re-sults were interpreted for both statistical and clinical sig-nificance based on the guidelines for minimal importantdifferences (MID) on the QoL scales [24].Study designThe feasibility study was a prospective, single-arm de-sign. Interested participants completed a baseline ques-tionnaire and were immediately provided with access tothe RiseTx web-based intervention.Trinh et al. International Journal of Behavioral Nutrition and Physical Activity  (2018) 15:49 Page 2 of 12The RiseTx interventionIn the first 10 days following recruitment, participantsmet with the research coordinator and were providedwith an accelerometer (GTX3, ActiGraph, Pensacola, FL,USA) and completed self-report baseline measures. Pro-vided along with the RiseTx intervention is the JawboneUP 24 (Jawbone, San Francisco, CA, USA), which is awrist-worn activity tracker that can assess activity pat-terns throughout the day and provide sensory alerts tostand after prolonged sitting (i.e., ≥30 min of sedentarytime). The intervention consisted of five phases follow-ing initial data collection, including a baseline phase(weeks 1–2; see Fig. 1). Phases I-III (weeks 3–6) involvedprogressive release of self-regulatory strategies (e.g., ac-tion planning) and targeted changes in both sitting time(and breaks in sitting time) and step counts. A 4-weekconsolidation phase (Phase IV and V; weeks 9–12)followed, where participants received weekly remindersthat encouraged them to continue to use the RiseTx appli-cation to practice combining the different self-regulatorystrategies learned in Phases I-III. Based on a previouslytested ramped step count approach that focuses on in-creasing walking by an extra 1000 daily steps over a setperiod [25], participants attempted to increase daily stepsby an additional + 1000 daily step increment set above theprevious phase (see Fig. 2).Incentives were built into the intervention to increaseengagement with the RiseTx application [26] such aslogging in to the website every day and reaching the stepgoal target for a particular phase. Rewards were accumu-lated in the form of points that could be redeemed for avariety of items and/or donating them to a charity ofchoice (maximum $50 CAD). Following the interven-tion, there was a 12-week maintenance period (weeks13–24) where participants no longer received weeklyself-regulatory practice reminders, yet still had access tothe application.MeasuresFeasibility measuresFeasibility was determined through rates of recruitment,measurement completion, attrition, intervention adher-ence (i.e., tracked through website analytics such as num-ber of logins), number of adverse events, and interventionevaluation items assessing burden and satisfaction. Ac-ceptability was measured through an intervention satisfac-tion survey completed at post-intervention assessingperceptions and overall impressions of the RiseTx inter-vention. A predefined success criteria was implemented tojudge the feasibility of the RiseTx intervention which wasbased on previous research [27–29] and included the fol-lowing: 1) study recruitment rates (~ 10 participantsFig. 1 RiseTx Application PhasesTrinh et al. International Journal of Behavioral Nutrition and Physical Activity  (2018) 15:49 Page 3 of 12Fig. 2 Sample Homepage from the RiseTx Web-based ApplicationTrinh et al. International Journal of Behavioral Nutrition and Physical Activity  (2018) 15:49 Page 4 of 12recruited per month over a 6-month period); 2) interven-tion adherence (≥ 3 visits by participants each week to theRiseTx platform; 3) measurement completion rates (≥75%complete baseline, post-intervention, and follow-up mea-sures); 4) attrition rates (≤20% drop-out rate); 5) accept-ability (> 75% rate their participation as satisfactory orvery satisfactory), 6) number of adverse events, and 7)intervention evaluation items assessing burden and satis-faction. Acceptability was measured through an interven-tion satisfaction survey completed at post-interventionassessing perceptions and overall impressions of theRiseTx intervention.Secondary outcomesAll measures were completed at baseline (T0),post-intervention (i.e., 12 weeks; T1) and follow-up (i.e.,24 weeks; T2). Standard demographic and medical vari-ables were also collected at baseline.Physical activity and sedentary behaviorChange in volume of SED and PA were measured byActiGraph Model GT3X accelerometers (Actigraph,Pensacola, Florida). A bout is defined as any continuousperiod of SED time with the bout stopped when > 100counts for an epoch are recorded. A break is defined asany 5-s epoch change from SED to light-intensity PA orgreater. Participants were asked to wear the accelerom-eter for seven consecutive days during waking hours,except for periods of bathing/showering or otherwater-based activities. Data were downloaded in 60-sepochs and converted to mean counts per minute to es-timate daily minutes of light (101–1951 counts•minute−1), moderate (1952–5724 counts•minute− 1), and vigor-ous (> 5725 counts•minute− 1) PA based on establishedcut-points [27], while controlling for the number of daysthe accelerometer was worn. Data were analyzed if therewere no extreme counts (> 20,000) and if data wereavailable for at least 600 min on 4 or more days per as-sessment period.Weekly step counts were collected using the JawboneUP24 (Aliphcom, San Francisco, CA) activity tracker.The monitor has a rechargeable battery and syncs to asmartphone or tablet via an Internet connection or Blue-tooth to upload step counts to the RiseTx website.Quality of lifeQoL was assessed by the validated Functional Assessmentof Cancer Therapy-General (FACT-G) which consists ofphysical well-being (PWB), functional well-being (FWB),emotional well-being (EWB), and social well-being (SWB)[30]. The FACT-Fatigue (FACT-F) scale included the 27items from the FACT-General (FACT-G) scale plus the 13item fatigue subscale [30, 31]. The PWB, FWB, and fatiguescales were summed to form the Trial OutcomeIndex-Fatigue (TOI-F) [30, 31]. We also included the vali-dated FACT-Prostate (FACT-P) subscale which contains12 questions that assess the most important targetedsymptoms and concerns for participants [32]. On allscales, higher scores indicate better QoL and lesssymptoms.Demographic and medical informationThe demographic variables included: age, marital status,highest level of education, current employment status,ethnicity, and height and weight to calculate body massindex (BMI). The medical variables included: time sincediagnosis, disease stage, ADT administration method,current/prior treatments, previous recurrence, andcurrent disease status, which have been used previouslyin studies with cancer survivors [21].Statistical analysisAll statistical analyses were performed using SPSS 23(SPSS Inc., Chicago, IL). Descriptive statistics were cal-culated to describe the sample population. Linear mixedmodels were used to model each outcome measure (i.e.,PA, SED, QoL) at the three time points [baseline (T0),post-intervention (i.e., 12 weeks; T1) and follow-up (i.e.,24 weeks; T2)]. Our analysis was adjusted for accelerom-eter wear time and baseline MVPA. For these analyses,all enrolled participants were retained regardless ofmissing data or incomplete participation. All statisticaltests were two-sided.ResultsThe flow of participants through the study is reported inFig. 3.Feasibility outcomesBriefly, 165 participants were screened for eligibility, ofwhom 94 met eligibility criteria. Of the 94 participantsthat met the eligibility criteria, 46 participants were inter-ested, generating a 49% response rate (46/94). On average,3 participants per month were recruited during the studyrecruitment period. Of the 46 participants enrolled in thestudy, 42 completed the SED intervention, representing a9% attrition rate or, conversely, a 91% retention rate.Measurement completion rates for self-reported outcomeswere 97 and 65% at post-intervention and 12-weekfollow-up, respectively.The overall adherence rate to the intervention was 72%(33/46) for total number of logins (i.e., > 3 visits eachweek). In terms of step counts, 59% of the 46 participants(n = 27) met the target step count for Phase 1 (i.e., + 1000steps above baseline), 46% met the target step count forPhase 2 (n = 21) (i.e., + 2000 steps above baseline), 39%met the target step count for Phase 3 (n = 18) (i.e., + 3000steps above baseline), and 35 and 26% of participants metTrinh et al. International Journal of Behavioral Nutrition and Physical Activity  (2018) 15:49 Page 5 of 12the target step count for Phase 4 (n = 16) and 5 (n = 12)(i.e., maintain + 3000 steps above baseline) respectively.Two participants experienced adverse events withone patient suffering a myocardial infarction and onepatient deceased for unknown causes during the inter-vention. However, it is unknown whether the two ad-verse events were related to the SED intervention asboth participants were provided with physician clear-ance and had no previous cardiac history before thestart of the study.Participant characteristicsBaseline demographic and medical characteristics, aswell as behavioral characteristics of participants are re-ported in Tables 1 and 2, respectively. Overall, partici-pants had a mean age of nearly 74 years, 84.8% weremarried, and the mean BMI was 28 kg/m2. The meannumber of months since diagnosis was 93.6 months,54.3% had received surgery, 63.0% had ADT adminis-tered continuously, and 65.2% reported localized pros-tate cancer. Participants spent 73.0% of their total timeFig. 3 Flow of Participants through the StudyTrinh et al. International Journal of Behavioral Nutrition and Physical Activity  (2018) 15:49 Page 6 of 12sedentary (525.9 min/day), 25.2% in light-intensity PA(192.5 min/day), and 1.8% in MVPA (14.3 min/day).Physical activity and sedentary behaviorTable 3 provides the change in SED and PA at baseline topost-intervention, and from baseline to 12-week follow-up.A significant reduction of 455.4 weekly minutes of seden-tary time was observed at post-intervention [95% CI: -766.6to 144.2; p = .005]. No significant effects were found forweekly minutes of sedentary time from baseline to 12-weekfollow-up. A significant increase of + 44.1 for weeklyminutes of MVPA was observed at post-intervention[95% CI: 11.1 to 77.0; p = .010], but no significant ef-fects were found at 12-week follow-up. There were nosignificant effects found for light-intensity PA frombaseline to post-intervention and at 12-week follow-up.Table 1 Demographic and medical characteristics of men withprostate cancer on androgen deprivation therapy in Toronto,Ontario, Canada, July 2015–October 2016 (N = 46)Variable Mean ± SD or n (%)Age 73.2 ± 7.3Marital StatusNever married 3 (6.5)Married/common law 39 (84.8)Widowed 2 (4.3)Divorced 2 (4.3)EducationSome high school 4 (8.7)Completed high school 4 (8.7)Some university/college 13 (28.3)Completed university/college 16 (34.8)Some/completed graduate school 9 (19.5)Employment statusEmployed full−/part-time 11 (23.9)Retired 34 (73.9)Other 1 (2.2)EthnicityWhite 37 (80.4)Black 4 (8.7)South Asian 2 (4.3)Southeast Asian 1 (2.2)Other 2 (4.3)Body mass index 28.0 ± 3.0Healthy weight 8 (17.4)Overweight 26 (56.5)Obese 12 (26.1)Number of comorbiditiesNone 4 (8.7)1 11 (23.9)2 14 (30.4)≥ 3 18 (36.9)aMost common comorbiditiesHigh blood pressure 27 (61.4)High cholesterol 19 (43.2)Arthritis 15 (34.1)Smoking statusNever smoked 23 (50.0)Ex-smoker 22 (47.8)Regular smoker 1 (2.2)Alcohol consumptionNever 8 (17.4)Less than once a month 7 (15.2)Table 1 Demographic and medical characteristics of men withprostate cancer on androgen deprivation therapy in Toronto,Ontario, Canada, July 2015–October 2016 (N = 46) (Continued)Variable Mean ± SD or n (%)2–3 times a month 5 (10.9)Once a week 4 (8.7)2–3 times a week 6 (13.0)4–6 times a week 8 (17.4)Every day 8 (17.4)Months since diagnosis 93.6 ± 71.2Disease stageLocalized 30 (65.2)Metastatic 15 (32.6)Unsure 1 (2.2)Androgen deprivation therapy administrationContinuous 29 (63.0)Intermittent 15 (32.6)Unsure 2 (4.3)aCurrent/prior prostate cancer treatmentSurgery 25 (54.3)Radiation 38 (82.6)Chemotherapy 3 (6.5)Current treatment statusCompleted treatment 19 (41.3)Receiving treatment 27 (58.7)Cancer disease recurrenceYes 16 (34.8)No 30 (65.2)Current cancer disease statusDisease-free 15 (32.6)Existing disease 31 (67.4)a could check more than oneTrinh et al. International Journal of Behavioral Nutrition and Physical Activity  (2018) 15:49 Page 7 of 12Step countsFigure 4 illustrates the step counts accumulatedthroughout baseline and Phases I-V of the intervention.There were significant increases in step counts of + 1535steps from baseline to post-intervention (p < .001).Quality of lifeTable 4 present changes in general QoL and cancer-specificQoL at baseline to post-intervention and at baselineto 12-week follow-up. There were significant improve-ments in EWB where there was a + 1.2 point differ-ence at post-intervention (95% CI: 0.2–2.1; p = .018),but not at 12-week follow-up. However, this was notmeaningful based on guidelines for minimally import-ant differences (MID). No significant effects were ob-served at post-intervention and 12-week follow-up forthe FACT subscales or other cancer-specific QoLmeasures.DiscussionTo our knowledge, the RiseTx intervention is the firststudy to pilot a SED intervention in PCS. The interven-tion met some feasibility indicators, but lacked sustainedengagement as indicated by the overall adherence rate.However, the intervention had high satisfaction and lowparticipant burden. Preliminary efficacy data suggest thatthere was a significant reduction of weekly minutes ofsedentary time and increase in weekly minutes of MVPAobserved at post-intervention. In addition, there weresignificant increases in step counts from baseline topost-intervention. However, few significant findings wereTable 2 Behavioral and quality of life characteristics of menwith prostate cancer on androgen deprivation therapy inToronto, Ontario, Canada, July 2015–October 2016 (N = 46)Variable M ± SDObjectively-assessed physical activity (N = 45)Average weekly light-intensity minutes 1239.2 ± 465.7Average light-intensity minutes per day 192.5 ± 62.4Percent time in light-intensity PA (%) 25.2 ± 6.9Average weekly MVPA minutes 93.1 ± 89.4Average MVPA minutes per day 14.3 ± 13.4Percent time in MVPA (%) 1.8 ± 1.6Objectively-assessed sedentary time (N = 45)Average weekly minutes 3514.4 ± 718.6Average minutes per day 525.9 ± 84.6Percent time in sedentary behavior (%) 73.0 ± 7.6Quality of lifePhysical well-being (0–28) 23.5 ± 3.8Functioning well-being (0–28) 19.7 ± 5.4Emotional well-being (0–28) 17.9 ± 5.2Social well-being (0–24) 20.1 ± 4.7FACT-General (0–108) 82.0 ± 13.4FACT-Fatigue (0–160) 122.1 ± 19.8FACT-Prostate (0–156) 114.9 ± 18.1Trial outcome index-Fatigue (0–108) 84.5 ± 14.4FACT Functional Assessment of Cancer Therapy, PA physical activity, MVPAmoderate-to-vigorous physical activityTable 3 Effects of a sedentary behavior intervention on activity levels in men with prostate cancer on androgen deprivation therapyin Toronto, Ontario, Canada, July 2015–October 2016 (N = 46)Baseline (T0) Post-intervention(T1)12-week Follow-Up(T2)aAdjusted Difference in MeanChange (T0-T1)aAdjusted Difference in MeanChange (T0-T2)Outcome Mean (SE) Mean (SE) Mean (SE) Mean [95% CI] p Mean [95% CI] pTotal SED minutes 3514.4 (105.7) 3058.9 (187.9) 3272.0 (157.2) -455.4 [-766.6 to -144.2] .005 − 242.4 [− 565.2 to 80.5] .14Total time spent in SEDbouts of ≥30 min1224.7 (65.9) 1078.0 (84.3) 1166.4 (88.6) − 148.7 [− 315.2 to 17.7] .079 −58.3 [− 262.1 to 145.5] .57Total # of breaks in timespent in SED bouts of≥30 min25.9 (1.4) 22.8 (1.8) 25.0 (1.9) −3.1 [− 6.4 to 0.4] .078 − 0.92 [− 5.1 to 3.3] .66Total Light PA minutes 1239.2 (70.0) 1148.2 (91.5) 1210.5 (80.1) −91.0 [− 236.4 to 54.4] .22 − 28.6 [− 198.2 to 141.0] .74Total MVPA minutes 93.1 (14.5) 137.1 (22.8) 122.1 (23.9) + 44.1 [11.1 to 77.0] .010 + 29.0 [− 14.2 to 72.2] .18Total # of MVPA boutsof ≥10 min4.3 (3.1) 3.1 (0.8) 2.4 (0.7) −1.2 [− 7.1 to 4.6] .67 − 1.9 [− 8.1 to 4.4] .55Total SED minutes: the total number of minutes spent in sedentary activity (defined as all minutes with an average activity count of < 100 counts•minute-1)Total time spent in SED bouts of ≥30 min: the total number of minutes spent in sedentary activity in a sedentary bout lasting ≥30 min. A sedentary bout isdefined as ≥1 consecutive minutes with < 100 counts•minute-1Total # of breaks in time spent in SED bouts of ≥30 min: the total number of interruptions (i.e., accelerometer counts per minute were ≥ 100) in sedentary timelasting ≥1 min in a sedentary bout lasting ≥30 minTotal # of MVPA bouts of ≥10 min: the total number of bouts spent in MVPA lasting ≥10 min. A MVPA bout is defined as ≥10 consecutive minutes with≥1952 counts•minute-1SED sedentary behavior, MVPA moderate-to-vigorous physical activityaDifference in mean change adjusted for accelerometer wear time and baseline MVPATrinh et al. International Journal of Behavioral Nutrition and Physical Activity  (2018) 15:49 Page 8 of 12observed at post-intervention and 12-week follow-up forthe QoL measures.While there are evidence-based interventions to in-crease MVPA in cancer survivors, much less is knownabout how to reduce SED which makes comparisonswith other studies scant. The recruitment rate of 49% inour study was higher than previous web-based interven-tions targeting cancer survivors that includes PCS [33].Our study generated a higher recruitment rate possiblydue to our intervention targeting SED, while Forbes etal. [33] focused on a web-based PA behavior change pro-gram. However, it is important to note that the recruit-ment rate in our study was extended over a 15-monthperiod. This was twice as long as was anticipated to re-cruit the sample needed. Our study focused on men onADT and it is unknown what the optimal timing to im-plement a lifestyle behavioral change during treatment.It is possible that some PCS were not ready to resumean active lifestyle or feel unwell to do so.The attrition rate of 9% or 91% retention rate wasaligned with previous digital health interventions for be-havior change among cancer survivors where Goode etal. [28] reported attrition rates between 6 and 45% forweb-based delivery methods, while Roberts et al. [29] re-ported retention rates between 31.7–100% for digitalhealth behavior change interventions. However, thesestudies were web-based interventions for PA and/orcombined PA and diet. SED may represent a behaviorthat is more achievable and sustainable compared to PA,which requires more planning and effort [34]. PCS mayfind a SED intervention more attractive than an inter-vention to increase MVPA.Adherence to our study was consistent with a previousmeta-analysis of internet-delivered interventions to in-crease PA in the general and chronic-diseased popula-tions. Davies et al. [34] found the average number oflogins was 3.08 per participant per week. Our adherencerate was higher compared to a previous web-basedFig. 4 Average Step Counts Across the Study Phases Measured by the Jawbone UP24 Activity Tracker (N = 46)Table 4 Effects of a Sedentary Behavior Intervention on Quality of Life in Men With Prostate Cancer on Androgen DeprivationTherapy in Toronto, Ontario, Canada, July 2015–October 2016 (N = 46)Baseline (T0) Post-intervention (T1) 12-week Follow-Up (T2) aAdjusted Difference inMean Change (T0-T1)aAdjusted Difference inMean Change (T0-T2)Outcome Mean (SE) Mean (SE) Mean (SE) Mean [95% CI] p Mean [95% CI] pPhysical Well-Being (0–28) 23.5 (0.6) 23.3 (0.6) 22.7 (0.8) −0.3 [−1.2 to 0.8] .59 −0.8 [−2.3 to 0.6] .27Social Well-Being (0–28) 19.7 (0.8) 19.7 (0.7) 19.2 (0.8) −0.0 [−1.6 to 1.6] .99 −0.6 [−2.6 to 1.5] .57Emotional Well-Being (0–24) 17.9 (0.8) 19.0 (0.7) 19.0 (0.7) + 1.2 [0.2 to 2.1] .018 + 1.1 [−0.2 to 2.4] .091Functional Well-Being (0–28) 20.9 (0.7) 20.0 (0.8) 19.8 (0.8) −0.8 [−2.0 to 0.3] .15 −1.1 [−2.7 to 0.5] .17FACT-General (0–108) 82.0 (2.0) 82.0 (2.1) 80.5 (2.2) + 0.0 [−2.6 to 2.6] .99 −1.6 [−5.3 to 2.2] .41FACT-Fatigue (0–160) 122.1 (2.9) 121.4 (3.4) 118.7 (3.5) −0.6 [−4.4 to 2.9] .68 −3.4 [−8.7 to 1.9] .20FACT-Prostate (0–156) 114.9 (2.7) 113.4 (3.0) 112.7 (3.2) −1.5 [−4.7 to 1.6] .33 −2.2 [−6.9 to 2.4] .34TOI-Fatigue (0–108) 84.5 (2.1) 82.6 (2.6) 80.7 (2.8) −1.9 [−4.9 to 1.1] .21 −3.8 [−8.2 to −0.6] .086Minimal important differences (MID) points for PWB (2–3); EWB (2–3); SWB (2–3); FWB (2–3); FACT-G (3–7); FACT-F (7); TOI-F (5); FACT-P (6–10)FACT Functional Assessment of Cancer Therapy, FACT-G Functional Assessment of Cancer Therapy-General, FACT-F Functional Assessment of Cancer Therapy-Fatigue, TOI-F Trial Outcome Index-Fatigue, FKSI-15 Kidney symptom index, SPA + EC Supervised physical activity plus exercise counseling, SPA + BC Supervisedphysical activity plus behavioral counselingaDifference in mean change adjusted for baseline valueTrinh et al. International Journal of Behavioral Nutrition and Physical Activity  (2018) 15:49 Page 9 of 12intervention targeting PA in cancer survivors. Similarly,a meta-analysis of digital health interventions targetingPA and diet in cancer survivors found website loginsranged from 1.00 to 14.75 times per week [29]. One po-tential reason for differences in our engagement levelswas that the RiseTx website required logging into thewebsite every day to view the number of steps taken. Wealso had a progressive release of support strategies andnew features of the website that were released in the first8 weeks of the intervention which may have maintainedthe interest. These behavior change techniques arealigned with technology-based strategies (e.g., real-timefeedback, tailored information) that are important forengagement [29, 35].In terms of our preliminary efficacy data, the RiseTxintervention was able to decrease SED by 7.6 h and4.0 h of sedentary time at post-intervention and at12-week follow-up, respectively. Sustained engagementis problematic for many digital health interventions withcancer survivors [28, 29, 34]. Our study had an overalladherence rate of 64% that while higher than previousstudies, still represents difficulties with engagement. Ourintervention integrated techniques to encourage engage-ment such as progressive release of support strategiesthroughout the phases of the intervention, reminders,user-friendly design, tailored and individualized compo-nents, and real-time feedback of step counts. Under-standing the techniques that foster effective engagementthroughout the intervention may be warranted.In addition, approximately half of PCS were able tomeet the target step count for the early phases of theintervention. However, during the maintenance phasesof the intervention, adherence to target step counts ta-pered off. It may have been too challenging for PCS toramp up to greater than 3000 steps during the mainten-ance phase given many of them are older and inactivePCS. Beginning the intervention with smaller incrementsto maintain the step counts over the course of the inter-vention may be more appropriate. It is interesting tonote that increases in step counts were reflected in in-creases in MVPA. For many older PCS, increasing walk-ing time is considered an aerobic activity where theintensity may have been at the level of MVPA ratherthan light-intensity PA [36]. However, these findingssuggest the utility of interventions combining the focuson reducing SED and increasing PA for PCS.Despite positive behavior change in our intervention, noclinically relevant changes were observed in many of theQoL measures. This is not surprising given the study wasunderpowered and many PCS had high QoL scores atbaseline. Previous studies examining objectively-assessedSED in colon cancer survivors [37] and PCS [17] andself-reported SED in PCS [38], have also demonstrated noor few associations with QoL.This is the first study to deliver a web-based interven-tion to reduce SED in cancer survivors and in PCS. Pre-liminary data demonstrated the support of a SEDintervention for reducing sitting time and increasingMVPA. Two adverse events occurred during the inter-vention and future research should consider exercisestress testing to screen for ischemic heart disease in pre-viously sedentary men who wish to become physicallyactive. Although our study experienced adverse events,light-intensity PA (i.e. walking) is generally regarded assafe and feasible for older adults, including PCS [13].The strengths of this study include the novel target insedentary time in cancer survivors, and the applicationof a simple and easy-to-use web-based intervention thatis scalable and has the potential to reduce sedentarytime. The intervention was also informed by preferencesof PCS based on formative research [21]. Moreover, theuse of objective measures of sedentary time via accelero-metry was beneficial for reducing recall bias. Futurestudies should consider using inclinometers (i.e., Activ-PALs) in conjunction with accelerometers for completedata. Limitations of this study include selection bias asPCS recruited into the study had to have an activee-mail address to participate. Given the feasibility study,we were unable to determine the elements of the inter-vention that were most important and effective for chan-ging sedentary time. It was unclear which combinationsof the intervention components would be optimal, andthis should be addressed in larger RCTs targeting SED incancer survivors.In conclusion, the RiseTx intervention was associatedwith a reduction in SED and increased MVPA amongPCS suggesting the utility and feasibility of interventionsthat target these behaviors simultaneously. Additionalstrategies may be needed for maintenance of behaviorchange for PCS, especially to continue engagement withthe website and to use the intervention components.Web-based interventions for SED are highly accessibleand offer an alternative approach for cancer survivorshipcare. Health professionals working with cancer survivorsshould consider encouraging a reduction in SED as aninitial step towards increasing activity levels for betterhealth outcomes in PCS.AbbreviationsADT: androgen deprivation therapy; BMI: body mass index; EWB: emotionalwell-being; FACT-G: Functional Assessment of Cancer Therapy-General; FACT-P: Functional Assessment of Cancer Therapy-Prostate; FWB: functional well-being; GU: genitourinary; MID: minimal important differences; MRC: MedicalResearch Council; MVPA: moderate-to-vigorous physical activity; PA: physicalactivity; PCS: prostate cancer survivors; PWB: physical well-being; QoL: qualityof life; SED: sedentary behavior; SWB: social well-being; TOI-F: Trial OutcomeIndex-FatigueAcknowledgementsThe authors would like to thank Mehala Subramaniepillai for her assistancein conducting this study.Trinh et al. International Journal of Behavioral Nutrition and Physical Activity  (2018) 15:49 Page 10 of 12FundingThis work was awarded a Prostate Cancer Canada Grant #D2013–12 and isproudly funded by the Movember Foundation. CMS is a Canada ResearchChair in Physical Activity and Mental Health. GEF is supported by a CanadianInstitutes of Health Research-Public Health Agency of Canada (CIHR-PHAC)Chair in Applied Public Health.Availability of data and materialsThe datasets used and/or analyzed during the current study are availablefrom the corresponding author on reasonable request.Authors’ contributionsGEF, CMS, KAN, SMHA, and JMJ contributed to the conceptualization anddesign of the study, obtained funding, interpretation of the data, anddrafting and revising the manuscript critically for important intellectualcontent. LT contributed to the design of the study, interpretation of thedata, and drafting and revising the manuscript critically for importantintellectual content. AL and SRB contributed to the interpretation of thedata, assisted with recruitment, and drafting and revising the manuscriptcritically for important intellectual content. All authors have read andapproved the final manuscript.Ethics approval and consent to participateEthical approval from the research ethics board from both recruiting siteswas obtained, and all participants provided written informed consent beforeinitiating study procedures.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Faculty of Kinesiology and Physical Education, University of Toronto,Toronto, ON, Canada. 2Sunnybrook Odette Cancer Centre, Toronto, ON,Canada. 3Department of Medicine, University Health Network & University ofToronto, Toronto, ON, Canada. 4Cancer Survivorship Program, PrincessMargaret Cancer Centre, Toronto, ON, Canada. 5School of Kinesiology,University of British Columbia, Vancouver, BC, Canada.Received: 30 September 2017 Accepted: 27 May 2018References1. 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