Abstract

1. Introduction

Breast cancer (BC) remains the most diagnosed cancer and the leading cause of cancer death among women in France (1). Treatment improvements have enhanced cancer survivorship, leading to a 5-year survival rate of 89% for people diagnosed with BC (1). These high cancer survival rates have led to increased exposure to physiological (e.g., fatigue, mobility problems) and psychological (e.g., anxiety, depression, low quality of life) adverse side effects associated with the disease and related common treatments (2).

One of the key non-pharmacological treatments showing promising results in managing these adverse effects are physical activity (PA) programs, implemented at each stage of the cancer progression. Indeed, PA interventions have been shown to enhance quality of life (QoL), reduce symptoms and simultaneously minimize the risk of recurrence and comorbidities among patients living with and beyond cancer (3–9). Based on these evidence-based benefits, a fencing program under the French acronym RIPOSTE (Reconstruction, Image de soi, Posture, Oncologie, Santé, Thérapie, Escrime) literally in English (Reconstruction, Self-Image, Posture, Oncology, Health, Therapy, Fencing) was created for BC surgery patients in 2014 (10). This adapted physical activity (APA) program has been considered by public health and medical stakeholders as an innovative intervention through fencing (10, 11). APA is defined as “a cross-disciplinary body of practical and theoretical knowledge directed toward impairments, activity limitations, and participation restrictions in physical activity” (12). The relevance of fencing as an APA program in the context of BC was suggested quite naturally, as it is well adapted to combating fatigue, pain and reduced arm mobility, as well as improving patients’ physical and psychological well-being (10, 13, 14). More specifically, the use of the saber (and not the foil or epee) allows maximum mobilization and opening of the shoulder, due to the particularity of this weapon. The RIPOSTE program will celebrate its 10th anniversary in 2024. Currently, over 100 fencing clubs offer this adapted fencing program in France and a few more abroad. The aim of the scientific committee is to further develop this program for as many clubs as possible, always with the same high-quality standards, and to spread more widely internationally. Contacts have already been established with the International Fencing Federation (IFF) and with some North American clubs, so that adapted fencing could be considered a valid non-pharmacological treatment worldwide. But more data on its benefits and implementation process is needed to anticipate this process (11, 15).

To date, despite large evidence on the benefits of PA for people with BC, the extent to which PA programs could be effectively adopted, implemented and sustained remains unclear (16–20). Previous literature has shown mixed results over the long-term impact of interventions on PA practice (16, 17). Indeed, several programs have achieved limited success in improving PA among adults, particularly due to a lack of maintenance and sustainability of practice once the intervention ends (18, 19). Also, the existing evidence has focused almost exclusively on the high internal validity – or the magnitude of effect as a key indicator for programs impact. However, issues related to external validity - how the results of a study can be generalized to other contexts (21) - received less attention (20). Assessing external validity when synthesizing the results of this type of program is important to support sustainably their translation into practice (22–24). An accurate and comprehensive evaluation of the system supporting the implementation process is needed in order to understand what works, for whom and how (25, 26).

While RIPOSTE program has provided some success on the field across France, its evaluation in terms of effectiveness and implementation process has remained at its infancy, with no proper evaluation so far. Determining the extent to which this program is effective, acceptable and implementable is a necessary preliminary step. These findings would help to enrich the literature on how to best intervene to enhance treatment and recovery among BC patients, considering both patient and professional preferences and adoption, to facilitate transfer from a research program to a field daily practice. The aim of this preliminary study was to evaluate the RIPOSTE program effectiveness and implementation process.

2. Method

2.1. Study design

A convergent mixed methods (QUAN+QUAL) pilot study was conducted using the framework to guide the planning and evaluation of programs according to the 5 following keys: Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework as a guide to evaluate RIPOSTE (27). Quantitative and qualitative data were collected at the same time and combined during data analysis in a convergent design, giving the same weight to each type of data. A commonly used framework to assess research implementation is the RE-AIM framework which conceptualizes the public health impact of interventions as a function of the 5 dimensions of RE-AIM ( Table 1 ) (28). This framework extends beyond standard measures of efficacy, considering individual and organizational factors that can either facilitate or impede the successful implementation and dissemination of a program (29, 30). A full description of the design and methodological protocol of the program have been reported previously (10). This research complies with the Helsinki declaration and received ethical authorization by the French committee for individual protection (CPP Sud Méditerranée IV, N°ID-RCB: 2020-A01916-33). This research is registered on clinicaltrials.gov (NCT04627714).

Table 1

RE-AIM components in the context of the RIPOSTE trial.

Dimension	Definition applied for this study	Outcome measures	Data sources
Reach	The proportion and representativeness of eligible individuals who participate in the program	-Absolute number of participants -Proportion of participants in the target population -Characteristics of participants compared to non-participants -Barriers and facilitators to participation according to participants, fencing masters and sports physicians	-Clinical examination -Interviews
Effectiveness	The effects of the program on relevant outcomes including behavioral and QoL outcomes	-Post-surgical effectiveness of fencing versus no fencing on 3-month QoL outcomes -Post-surgical effectiveness of fencing versus no fencing on 3-month changes in global shoulder functional capacity, fatigue, anxiety-depression and PA -Measure of inter-individual differences related to individual characteristics	-Clinical examination -QLQ-C30 -QLQ-BR23 -DASH -MFI-20 -HADS
Adoption	The proportion and representativeness of patients that adopt the program	-Participation and withdrawal rates -Number of sessions attended out of total number of sessions (per participant) -Barriers and facilitators to patients uptaking the program according to participants, fencing masters and doctors	-Interviews
Implementation	The fidelity of the program to the various elements of its key functions and components	-Consistency of implementation (across individuals/time/settings) -Adaptations made to intervention during study -Participant and professional perceptions of the barriers and facilitators to implementation	-Interviews
Maintenance	Long-term effects of the program on behavior maintenance	-Continuation of RIPOSTE or PA by participants -Program perspectives -Prospects for change or improvement in future implementation (according to sports physicians, fencing masters and researchers)	-Interviews

Open in a separate window

2.2. Participants and recruitment

From November 10^th to January 19^th 2021, patients diagnosed with invasive BC were screened from 3 centers in Northeastern France (University Hospital of Nancy CHRU, France), Institut de Cancérologie de Lorraine, Nancy, France and Hôpital d’Instruction des Armées Legouest, Metz, France). Among the 309 patients screened, 24 met the inclusion criteria (10) and were selected from those who had recently undergone breast surgery for invasive BC. The surgeon, anesthesiologist or oncologist referred them to a sports physician within 2 to 4 weeks after surgery for an inclusion visit. All participants were provided with an information letter outlining the research and completed written informed consent. Patients were then randomized, with centralized 1:1 computerized requested via the web interface (e-crf) by the investigator with a sequential minimization of factor 85%, to one of two groups. The Early RIPOSTE group received one fencing session (duration of 1–1.5 h/session) per week from inclusion and for 3 months in the program. The Delayed RIPOSTE group received a follow-up without fencing for the first 3 months after inclusion and then the program (i.e. one fencing session per week) for the last 3 months (see Figure 1 for sample allocation and intervention description). Recruitment occurred between November 2021 and January 2022. They followed fencing sessions that had a common structure in the fencing French halls in the cities of Vandoeuvre-lès-Nancy and Thionville. Participation in all sessions was not required to be considered a study participant, but the level of participation was analyzed as a reach indicator.

Open in a separate window

Figure 1

Study design and patient allocation.

3. Results

In order to best reflect the aims of the study, the results are presented under the RE-AIM framework.

3.1. Reach

3.1.1. Number and proportion of participants

Among the 309 patients screened, 73 were eligible for enrollment. Among them, 49 were not included (refusal) so 24 patients were allocated either in the Early RIPOSTE group (n = 11) or the Delayed RIPOSTE group (n = 13).

3.1.2. Characteristics of participants

Sociodemographic and clinical characteristics of the study sample are presented in Table 2 .

Table 2

Sociodemographic and clinical characteristics of the study sample.

	Early RIPOSTE		Delayed RIPOSTE		Total		stdiff†
	N=11		N=13		N=24
Age							0.094
Mean (SD)	58.8 (10.84)		57.7 (13.03)		58.2 (11.83)
Family situation
Living alone	3	(27.3%)	4	(30.8%)	7	(29.2%)	0.077
Living with:	8	(72.7%)	9	(69.2%)	17	(70.8%)
Spouse/Partner	7	(63.6%)	9	(69.2%)	16	(66.7%)	0.119
Children	0	(0.0%)	1	(7.7%)	1	(4.2%)	0.408
Parents	0	(0.0%)	0	(0.0%)	0	(0.0%)	N/A
Other	1	(9.1%)	0	(0.0%)	1	(4.2%)	0.447
Marital status							0.668
NR	1		0		1
Married	5	(45.5%)	7	(53.8%)	12	(50.0%)
Civil union partner	2	(18.2%)	2	(15.4%)	4	(16.7%)
Single	1	(9.1%)	1	(7.7%)	2	(8.3%)
Separated	1	(9.1%)	0	(0.0%)	1	(4.2%)
Divorced	1	(9.1%)	2	(15.4%)	3	(12.5%)
Widowed	0	(0.0%)	1	(7.7%)	1	(4.2%)
Number of children							0.487
Mean (SD)	2.0 (1.95)		1.2 (1.09)		1.6 (1.56)
Socio-professional category							0.666
Farmers	0	(0.0%)	0	(0.0%)	0	(0.0%)
Craftsman, shopkeeper and business owner	1	(9.1%)	1	(7.7%)	2	(8.3%)
Executives and higher intellectual professions	4	(36.4%)	5	(38.5%)	9	(37.5%)
Intermediate profession	0	(0.0%)	1	(7.7%)	1	(4.2%)
Employees	4	(36.4%)	4	(30.8%)	8	(33.3%)
Workers	0	(0.0%)	0	(0.0%)	0	(0.0%)
Retired	1	(9.1%)	2	(15.4%)	3	(12.5%)
Without Professional activity	1	(9.1%)	0	(0.0%)	1	(4.2%)
Having a caregiver							0.408
NR	1		0		1
No	10	(90.9%)	12	(92.3%)	22	(91.7%)
Yes	0	(0.0%)	1	(7.7%)	1	(4.2%)
Number of days since diagnostic							0.157
Mean (SD)	114.8 (91.71)		131.3 (116.30)		123.8 (103.85)
Disease stage							0.570
Stage 1	3	(27.3%)	2	(15.4%)	5	(20.8%)
Stage 2	5	(45.5%)	8	(61.5%)	13	(54.2%)
Stage 3	3	(27.3%)	2	(15.4%)	5	(20.8%)
Stage 4	0	(0.0%)	1	(7.7%)	1	(4.2%)
Number of days since breast surgery							0.082
Mean (SD)	18.5 (7.58)		19.0 (5.58)		18.8 (6.43)
Type of treatment
Mastectomy	9	(81.8%)	11	(84.6%)	20	(83.3%)	0.075
Tumorectomy	8	(72.7%)	9	(69.2%)	17	(70.8%)	0.077
Radiotherapy							0.194
NR	1		0		1
No	6	(54.5%)	9	(69.2%)	15	(62.5%)
Yes	4	(36.4%)	4	(30.8%)	8	(33.3%)
Chemotherapy							0.354
NR	1		0		1
No	7	(63.6%)	11	(84.6%)	18	(75.0%)
Yes	3	(27.3%)	2	(15.4%)	5	(20.8%)

Open in a separate window

†Standardized difference (stdiff) = effect size (Yang, D., & Dalton, J. E. (2012). A unified approach to measuring the effect size between two groups using SAS^®. 6).

3.1.3. Profile and reasons for participation

Participant’s quotations in regard to their participation and experience are described in Table 3 . Elderly or sedentary patients were less likely to participate, or the sports medicine physician did not suggest the program to them. Most of the participants were dynamic and physically active prior to their cancer. The main reasons for participation were the originality of fencing, the symbolism of “combat”, and the fact that the program was free, as well as known to sports medicine physicians. Their participation was also motivated by a desire to take control over their lives and distance themselves from the cancer environment. At the same time, most patients saw the program as an opportunity to improve disease-related symptoms and manage the side effects of treatment. A few were more interested in taking part in a study and contributing to cancer research. While some participants expressed a desire to share an activity with other cancer survivors, the more introverted ones were held back by the collective dimension of fencing. From an organizational point of view, the distance between home and the fencing gym, the day and time suited most of the participants, principally because they were no longer working and therefore had few constraints. However, those with children regretted that the training sessions were not offered during school hours.

Table 3

Participant’s quotation in regard to their participation and experience to RIPOSTE.

	Category	Quotes
Reasons for participation	Dynamic and active profiles	« There are probably people for whom it didn’t even occur to me to suggest it because they didn’t have the right profile. They may be ladies who are too old, or not at all dynamic. (…) It’s an almost unconscious selection. (…) I’m sure there are people who missed out, I didn’t systematically suggest it to everyone. » (SP2) « The problem with all these adapted physical activity programs is that the people who respond to them are people who are convinced that physical activity is important, and in the end they are people who were already somewhat athletic before or who already practiced physical activities. (…) The profile of the patients is rather young and dynamic. » (SP2)
	Originality of fencing	« It’s an original and little-known sports program, and one that arouses the curiosity of patients. » (SP1)
	Symbolism of « combat » associated with fencing	« That is also a fight against us, against what happens to us. So in the fact of having a saber and doing fencing, there is also the symbolism “we defend ourselves”. On a psychological level, I find it good to have this approach (…) of someone who defends herself. » (P1)
	Good knowledge of the program among sports physicians	« I took the time to meet the fencing master and visit the weapons room. (…) Having been there and seen things with my own eyes, and having done a year of fencing myself, (…) I think that made it easier for me. (…) I knew what it was and where I was sending my patients. » (SP2) « We know what we’re really talking about, we know which programs we’re sending our patients to. I think that’s essential. You can never explain things as well as when you know what you’re talking about. (…) Because if you’re just giving a succinct presentation, telling them they can do fencing and that’s what’s on offer, it’s not the same as if you’re really convinced that it’s a great activity and that it won’t be harmful for them because we’ve tried it ourselves. And I think that’s obviously not the same way of presenting things. » (SP2)
	Getting out of the cancer environment	« It was going to take me out of the context of the hospital, the treatments.» (P2)
	Improvement of symptoms and side effects	« I thought it would be a good rehabilitation (…) for my breast, for my arm. » (P7)
	Improvement of general well-being	« It is the fact of wanting to stay in shape, in good health, to age well, to heal better perhaps. » (P1)
	Collective dimension	« Curious (…) to share. Because I told them it was with other patients who had the same pathologies. So they were curious to meet other people too, to be able to talk, to take their minds off things. » (SP1)
	Participation in cancer research	« For others. Honestly, that’s what made me want to do it. Because if I had wanted to do sports for myself, I would have gone to the pool or done my own sports in my corner actually. So I go back to giving a little something to other patients, to research, to studies. » (P4)
	Day and time	« Friday morning was good. (…) The schedules were good. Most of us haven’t gone back to work yet, so it was good. » (P10)
	Distance between home and the fencing gym	« I didn’t live far from Nancy. (…) Distance played a role. » (P9)
	Free access	« There is the fact that it is free. (…) And that’s good because otherwise it’s a barrier. Because, honestly, for three months, I wouldn’t have paid. » (P8) « Fencing isn’t the cheapest sport in the world, let’s face it. That’s why we wanted the program to be free for patients, at least for the first year. » (SP3)
Reasons for non-participation	Collective dimension	« It can be a bonding experience for those who need it most (…) I’m pretty self-sufficient and lonely, so I prefer activities I can do alone. » (P6) « Some people find it very convenient to get together with others who are going through the same thing. And there are people who, on the contrary, don’t feel like it. (…) So it’s a question of choice. (…) If it’s not their character, if they’re more introverted and don’t want to talk to other people, it’s not for them. I think one of the essential things for a physical activity to work is for the patient to adhere to it and enjoy it. If it goes against what they like to do, it won’t work. The obstacle can be the group aspect and the patient group aspect. » (SP2)
	Day and time	« It’s true that a time slot during working hours also has its limits. Because when patients return to work part-time or full-time, therapeutic or otherwise, it’s certainly complicated to free up time from 10am to 12pm, for example. (…) So I think the choice of time slot is important. » (SP3) « I would really prefer it to be during school hours because I have my children who go to school. (…) And there, it was annoying because I couldn’t pick them up. (…) So when we’re off work, I admit I prefer it to be during school hours. » (P8)
	Distance between home and the fencing gym	« I wouldn’t have been willing to travel miles to participate in an activity. (…) I think it must be difficult to reach people who are further away to come and do an activity. That’s my point of view. » (P9) « I think the main obstacle was distance. It was the people who didn’t live nearby. (…) It’s true that some people gave up because of the distance. (…) On the other hand, people who live in Vandoeuvre or the greater Nancy area are very happy to find something nearby. » (SP2)

Open in a separate window

4. Discussion

To achieve greater dissemination and generalization of PA programs, one of the current challenges is to address the lack of translation of evidence-based research protocols into practice (38, 39). A recent review by Klesges et al. highlighted the importance of considering dissemination when designing health promotion programs (40), but few behavioral intervention evaluations reported evidence of external validity of RE-AIM criteria (41). To our knowledge, our pilot study is the first to evaluate the RIPOSTE program effectiveness and implementation process using the RE-AIM framework. The RE-AIM model proved useful in highlighting the complexities of RIPOSTE implementation and evaluation, which could lead to a more complete program that addresses issues related to improving the external and internal validity of translating research into practical-generalizable practice.

Reach among all patients was good (24 patients, i.e. around a third of eligible patients). Most participants were young and dynamic and had expectations and beliefs about program outcomes. Similarly, BC survivors who exercise regularly report significantly more positive attitudes towards their physical condition, higher body esteem, better mood and higher vigor than sedentary (42). Psychological or physical, barriers to participation were mainly related to fatigue and pain. Difficulties in reaching older or sedentary patients could then be explained by differences in their existing abilities, but also in their motivation and beliefs. Previous studies have established that there are significant differences in perceived barriers to PA as a function of age and activity level (43). Older people’s motivation to engage in PA is particularly influenced by socio-cognitive variables such as their perceived physical frailty and poor health, perceived self-efficacy, perceived social support or perceived benefits/barriers to continued PA (44). It has been shown that older adults may have prevailing social beliefs that exercise is inappropriate, or even harmful, for them, or that they may be unaware of the importance of regular PA in preserving their health (45, 46). Participation may also be influenced by PA preferences, which are subjective constructs that prioritize choices, influenced by structural, interpersonal and intrapersonal factors (47, 48). The higher level of participation among young patients could be partly due to the match between the sports on offer - described as innovative and original - and their preferences (48, 49). Taking these preferences into account could make it possible to adapt the offer and support the involvement of all patients in PA. This highlights a further reach challenge in trying to recruit older, sedentary patients, as these are often the ones who need it most.

There is a high level of evidence supporting the benefits of PA programs in breast cancer. More precisely, PA interventions have been shown to enhance QoL, reduce symptoms and adverse effects of medical treatments and above all decrease the risk of recurrence and comorbidities (3–9). However, less information was available regarding the nature and the timing for such PA interventions in breast cancer. In a systematic review (50) aimed to assess the effects of Olympic combat sport on health QoL, only 6 studies were available and only one concerned fencing and breast cancer (51). Overall, it appears that interventions based on Olympic combat sports produce beneficial effects on health QoL. Another review also showed that Olympic combat sport improves older adults physiological and physical health (52). Our study (10) allows to more precisely explore the potential effects of adapted fencing after breast cancer surgery, considering a different timing among patients (i.e. “Early” vs “Delayed” RIPOSTE program). Therefore, we can’t conclude to a superiority (in terms of QoL) of starting RIPOSTE early (i.e. 4 weeks after surgery) vs starting later (i.e. 3 months after surgery). The lack of statistical significance of the results despite an overall trend towards a more favorable effect in the “Early RIPOSTE” group can however be explained by various reasons. First, the small size of our pilot study doesn’t allow to have enough statistical power to show a significant difference. This is consistent with the calculation of the minimum detectable difference when planning the study. Indeed, we had calculated a predicted minimum detectable difference of 12 points of QoL, but the observed difference is 6.1 points. This should be considered to adjust the hypotheses for calculating the number of subjects required when setting up a larger study in the future. In addition, we also observed differences in clinical characteristics and perceived health at baseline between our two groups (DASH and HADS scores). Indeed, almost all of the baseline clinical and perceived health criteria, were more favorable in the “Early RIPOSTE” group compared to the “Delayed RIPOSTE” group. Of course, probabilistic randomization was done, but it could not correct these initial differences. It would then be appropriate in a future study to increase the size of the included population also allowing to target or identify more particularly the patients according to diseases stages (subgroup analysis) to help highlight a difference.

On the other hand, and as a corollary to our results (i.e. only a trend for a better improvement of QoL in the “Early RIPOSTE” group), we can also suggest, because of the absence of significant difference between the 2 groups, that starting adapted fencing early is not more harmful than starting it later. This message is important, because it’s still regularly considered that a rapid/early resumption of physical activity can be harmful for the patient (risk of injury, risk for the surgical scar in particular). Offering an adapted fencing program, with trained fencing masters and under cover of medical examinations (performed by certified sports medical doctors) should therefore be considered as key elements of the RIPOSTE program, and also a guarantee of quality and patient’s safety. The qualitative analysis also provides interesting feedback on the RIPOSTE program, showing that it has been largely adopted and implemented.

Data demonstrate that participants adopted the program, largely because of the physical and moral benefits associated with the practice, regardless of the timing of the intervention. These beneficial effects were probably influenced by the diversity and richness of the exercises proposed, which were appreciated, as well as by the good group cohesion, support and exchanges that punctuated the sessions and facilitated the patients’ experience of the disease. In line with previous research, camaraderie and friendship within a small group are important reasons why BC survivors adopt PA (53, 54), helping them to feel accepted and supported by “similar others” (54). Some participants were motivated by sharing experiences around cancer, while others adopted the program because it enabled them to distance themselves from their illness. RIPOSTE offered women the opportunity to define and listen to their own specific needs and interests. The program thus seems to have fostered autonomy and behavioral control, key factors in behavior change according to the theoretical underpinnings of the self-determination theory (55) and theory of planned behavior (56). Financial barriers are one of the reasons why many BC survivors don’t make PA a priority after treatment (57). The free nature of the program has played a key role in its adoption by patients, offering them the opportunity to try an activity they hadn’t considered or didn’t think was aligned to their capabilities. We also feel it’s important to reconsider the organizational aspects that could act as a barrier to adoption, by adapting more closely to participants’ availability, particularly in terms of school or work schedules, and by remedying the interruption of sessions during school vacations. The lack of intensity mentioned by some participants as a barrier to adoption could be linked to the size of the group, which is sometimes too large, or to the arrival of new participants during the program, which slows down the group’s progress. Despite this, our results emphasize the success of the program, which depended in part on good supervision of the fencing masters. To ensure the sustainability of the intervention, it is essential to ensure that participants receive adequate supervision and support.

Implementation of the protocol elements was stable throughout the intervention. Assessing barriers to implementation while the program was ongoing enabled professionals to modify the organization and overcome the most common barriers, for example by setting the duration of sessions at 2 hours. Fencing masters also used social networks to communicate with participants and deal with unforeseen circumstances. In future, setting the number of participants at 10 or 12 would enable participants to train in pairs under optimum conditions, with the opportunity to work individually with the fencing master. Particular attention will need to be paid to the equipment, so that it is adapted to the patients’ physical particularities.

By creating a motivating and supportive environment, group PA programs are considered an effective way of encouraging BC survivors to maintain PA (54). As many participants started to notice positive changes in their health (e.g. arm and breast rehabilitation and reduced fatigue), it seems that their motivation to maintain PA after the program was enhanced, as indicated in the interviews. However, we have little follow-up data on this dimension, as participants’ continuation of PA has not been evaluated over the long term. The lack of reported long-term maintenance information is problematic, as it limits the estimation of the long-term impact of the program. We believe that additional strategies are needed to encourage and support the continuation of the intervention. Patient follow-up and support could be improved, for example by implementing collaboration and communication strategies between sports physicians and fencing masters, but also with other healthcare professionals such as psychologists. Another idea for doing so would be to add follow-up assessments, which would take place at least 6 months after the end of the intervention, and which would report on its degree of sustainability.

5. Conclusion

This randomized pilot trial mainly reached young and dynamic patients, and demonstrated strong effects in the dimensions of adoption and implementation. While organizational factors such as time, setting and equipment have a major influence on the successful adoption and implementation of this type of intervention, the implementation of follow-up and support strategies for patients seems essential to adapt the offer to their needs and preferences. Participants’ abilities, social support or any physical and/or psychological difficulties are all factors to be taken into account when offering APA in a context as specific as that of cancer. Intervention effectiveness and maintenance require further attention and innovation to confirm the overall positive trends. Increasing the size of the included population and the number of centers involved (i.e. multicentric study), and using more rigorous measures to assess PA maintenance are needed in future research.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by French ethics committee: Comité de Protection des Personnes Sud Méditerranée IV, N°ID-RCB: 2020-A01916-33. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

SH: Writing – review & editing, Formal analysis. AV: Writing – review & editing, Writing – original draft, Validation, Supervision, Methodology, Formal analysis. MS: Writing – review & editing, Software, Methodology. CR: Writing – review & editing, Methodology, Funding acquisition, Formal analysis, Conceptualization. AC: Writing – review & editing, Project administration, Data curation. DP: Writing – review & editing, Validation, Supervision, Conceptualization. CD: Writing – review & editing, Supervision, Investigation, Formal analysis, Conceptualization. JR: Writing – review & editing, Supervision, Formal analysis. MT: Writing – review & editing, Supervision, Investigation, Formal analysis. EA: Writing – review & editing, Validation, Formal analysis. OH: Validation, Formal analysis, Writing – review & editing. BC: Writing – review & editing, Validation, Formal analysis. DH: Writing – review & editing, Validation, Supervision, Formal analysis, Conceptualization. AO: Writing – review & editing, Writing – original draft, Validation, Supervision, Project administration, Methodology, Funding acquisition, Formal analysis, Conceptualization. MP: Writing – original draft, Validation, Supervision, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization, Writing – review & editing.

Acknowledgments

Funding Statement

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This study was supported by la Ligue Interrégionale Grand Est contre le Cancer and the Région Grand Est and Pôle Biologie Médecine Santé de l'Université de Lorraine, through a doctoral grant.

References