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. 2025 Apr 28;131(9):e35798. doi: 10.1002/cncr.35798

Feasibility and acceptability of the Comprehensive Oncology Rehabilitation and Exercise (CORE) clinical workflow algorithm in patients with newly diagnosed stage I–III breast cancer who undergo surgery as first‐line treatment

Lea Haverbeck Simon 1, Carson Saviers‐Steiger 2, Emily R Dunston 3, Patrick Galyean 4, Elisabeth R Kimball 4, Justine Mendez 4, Susan L Zickmund 4,5, Pamela A Hansen 2,6, Cornelia M Ulrich 2,7, Paul C LaStayo 8, David Steinberg 6, Christopher S Noren 9, A’Lisha Finch 2, Leanne Seckinger 9, Emma Braun 7, Jonathan Chipman 1,7, Kirstyn E Brownson 2,10, Sonal Oza 2,6,11, Adriana M Coletta 1,3,✉
PMCID: PMC12035508  PMID: 40289623

Abstract

Background

This pilot, mixed‐methods, randomized controlled trial determined the feasibility and acceptability of the Comprehensive Oncology Rehabilitation and Exercise (CORE) clinical workflow algorithm. CORE was designed to connect patients with newly diagnosed breast cancer to exercise and rehabilitation services from the time of diagnosis throughout cancer care.

Methods

In total, 72 patients with newly diagnosed, stage I–III breast cancer who required surgery as first‐line treatment were randomized 2:1 to CORE or standard of care. CORE included a triaging tool of two questionnaires regarding self‐reported exercise (the Godin Leisure Time physical activity questionnaire) and functional status (the Patient‐Reported Outcomes Measurement Information System physical function questionnaire), which were administered at the check‐in desk for routine breast surgical oncology clinic visits at the initial surgical consultation, postoperatively, and 24 weeks after surgery. Responses to questionnaires in the triaging tool triaged participants to one of three pathways within the algorithm: exercise service, rehabilitation service, or exercise self‐management (not a service). Service pathways required referral by clinic staff. Feasibility was determined based on completing the triaging tool (≥66%) and referral completion (≥50%) at the initial surgical consultation visit. Acceptability was determined by four study participant focus groups and one clinic team focus group (≥50% positive response).

Results

Ninety‐three percent of participants in CORE (n = 40) completed the triaging tool. Among those triaged to a service pathway (n = 29), 62% completed their referral. Focus group feedback was primarily positive.

Conclusions

The CORE clinical workflow algorithm is feasible and acceptable among women who have newly diagnosed stage I–III breast cancer with plans for surgery as first‐line treatment. CORE was also acceptable among clinic staff.

Clinical Trials Registration

NCT04594473

Keywords: breast cancer, cancer rehabilitation, clinical workflow, exercise oncology, health services

Short abstract

The Comprehensive Oncology Rehabilitation and Exercise clinical workflow algorithm tested in this mixed‐methods pilot study among women newly diagnosed with stage I–III breast cancer who had plans for surgery as first‐line treatment was feasible and acceptable. This work supports national efforts to make exercise and rehabilitation services part of routine cancer care, and the Comprehensive Oncology Rehabilitation and Exercise clinical workflow algorithm could serve as a model for cancer centers nationwide.

INTRODUCTION

Breast cancer is the most prevalent cancer type in women, and exercise postdiagnosis is associated with a 31% and 41% reduction in cancer‐specific and all‐cause mortality, respectively. 1 , 2 Exercise across the breast cancer care continuum (i.e., after diagnosis and before, during, and after treatment) attenuates declines in physical function and improves independence, fitness, strength, fatigue, quality of life, anxiety, depression, bone health, sleep quality, lymphedema, and shoulder range of motion. 3 , 4 , 5 , 6 Both the American College of Sports Medicine (ACSM) and the American Society of Clinical Oncology (ASCO) now recommend exercise across the cancer care continuum. 6 , 7 , 8 Exercise services are designed to improve mild functional deficits and physical deconditioning, such as fitness and strength. 9 Exercise services and rehabilitation services are complementary. Rehabilitation services treat neurologic and musculoskeletal deficits, such as impaired shoulder range of motion and peripheral nerve injury. 9 Depending on where the patient is on the cancer care continuum, they may require both services concurrently or in tandem throughout care, underpinning the synergy between both professions, the need to include both services as part of routine cancer care, and the need for multiple assessments across the care continuum. 9

Currently, there are few health care models that integrate both exercise and rehabilitation services into one clinical workflow. 10 , 11 , 12 , 13 , 14 None of these models evaluate needs at multiple timepoints throughout care to address the gap in care delivery. To address this gap, the purpose of this study was to determine the feasibility and acceptability of a clinical workflow algorithm, named CORE (Comprehensive Oncology Rehabilitation and Exercise), which was designed to connect patients with breast cancer to needed exercise and rehabilitation services from the time of diagnosis and throughout care.

MATERIALS AND METHODS

Study design and participants

The CORE trial was a 24‐week, mixed methods, parallel, randomized controlled pilot trial aimed at testing the feasibility and acceptability of a clinical workflow algorithm that connects patients who have newly diagnosed stage I–III breast cancer and plan to undergo surgery as first‐line treatment with needed exercise and rehabilitation services from diagnosis and throughout care. The qualitative and mixed‐methods framework used for this trial was the Patient‐Centered Outcomes Research Institute's methodology standards. 15 Women were recruited from breast surgical oncology clinics at the Huntsman Cancer Institute in Salt Lake City, Utah. Women with metastatic breast cancer or stage I–III breast cancer who had plans for neoadjuvant chemotherapy were not eligible. This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the University of Utah (Institutional Review Board no. 00137018), and the trial is registered in ClinicalTrials.gov (identifier NCT04594473).

Seventy‐two patients with breast cancer were randomized to CORE or the standard of care (SOC) at a 2:1 ratio. Block randomization, with three participants per block, was stratified by adherence (yes/no) to national physical activity (PA) guidelines. Informed consent was obtained from patients after diagnosis and before the routine breast surgical consultation visit. Upon obtaining informed consent, screening and enrollment occurred; then, participants completed the modified Godin Leisure Time PA questionnaire to determine guideline adherence and enable randomization. These procedures occurred before baseline procedures. Study day assessments to evaluate differences between CORE and SOC for physical function, quality of life, and exercise engagement occurred at the breast surgical consultation visit, the first postoperative visit, and the visit 24 weeks after surgery. Data from these assessments will be presented elsewhere.

Standard‐of‐care arm

Participants randomized to SOC (n = 25) followed routine clinical procedures and were instructed to continue their typical lifestyle activities during the entirety of the study.

CORE intervention arm

The CORE clinical workflow algorithm triaged patients to exercise or rehabilitation services throughout the first 24 weeks of breast cancer care. A triaging tool using two questionnaires about exercise engagement and functional status was administered at the following routine clinic visits with breast surgical oncology: the initial surgical consultation, the first postoperative visit, and the visit 24 weeks after surgery. Upon arrival for each routine clinic visit, clinic staff at the check‐in desk handed participants an iPad (Apple Inc.) to complete the questionnaires; this is why participants were randomized before their breast surgical consultation visit. Responses to these questionnaires dictated the pathway within the clinical workflow algorithm to which the participant should be triaged: (1) exercise self‐management (not a service pathway), (2) exercise service, (3) or physical medicine and rehabilitation (PM&R) service. Clinic staff then made necessary referrals to service pathways (exercise or PM&R), and the referred services would reach out to participants for scheduling.

CORE clinical workflow algorithm overview

A study advisory board was established, consisting of the investigative team and key stakeholders at the institution, and was responsible for developing the CORE clinical workflow algorithm and triaging tool. Key stakeholders consisted of individuals in the following roles: Executive Director of the Comprehensive Cancer Center, Executive Medical Director of the Rehabilitation Hospital, Director of Therapy Services, Therapy Services Coordinator, Medical Director of the Exercise Service, Senior Director of Nursing, Rehabilitation Research Investigators, and Manager of Patient Navigation Services. Figure 1 provides an overview of the CORE clinical workflow algorithm.

FIGURE 1.

FIGURE 1

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The CORE clinical workflow algorithm. *Occurred at routine visits with breast surgical oncology: the initial surgical consultation, the first postoperative visit, and the visit 24 weeks after surgery visit. **The hospital‐based exercise oncology program described in this study is the Huntsman Cancer Institute's POWER program, which is offered in the institution's Wellness and Integrative Health Center. The medical and physical assessment within the POWER program is conducted by PM&R physicians; thus, after the first assessment in the POWER program, a patient may also be referred to a rehabilitation service, such as PT or OT, if needed. CORE indicates Comprehensive Oncology Rehabilitation and Exercise; OT, occupational therapy; PM&R, physical medicine and rehabilitation; POWER, Personal Optimism with Exercise Recovery; PT, physical therapy; Rehab, rehabilitation.

The algorithm consisted of three pathways. The exercise self‐management pathway was for individuals who reported meeting PA guidelines with no declines in function. The exercise service pathway consisted of the Huntsman Cancer Institute's established, effective, hospital‐based exercise oncology program, Personal Optimism With Exercise Recovery, which is available to patients at the cancer center's Integrative Health and Wellness Center. A detailed description of the Personal Optimism With Exercise Recovery program and its demonstrated effectiveness is provided elsewhere. 16 The PM&R service pathway is meant for individuals with complex, moderate or severe functional deficits of the neurologic, musculoskeletal, or cardiopulmonary systems. This pathway consists of an appointment with a PM&R physician. As part of the PM&R service, the physician will decide whether the patient needs a referral to other rehabilitation services, such as physical therapy, 9 or can be referred to begin exercise services.

CORE algorithm triaging tool

Two short, validated questionnaires were administered by clinic staff at the check‐in desk using iPads at the aforementioned routine breast surgical oncology clinic visits. It was determined by the study advisory board that administration of these questionnaires by staff at check‐in would ensure consistency across breast surgical oncology clinics. Responses to these questionnaires identified the pathway to which a participant would be triaged within the algorithm. Administration of the questionnaires at these times allowed for continued assessment of individual physical needs because these needs change throughout care. Note that, the CORE clinical workflow algorithm includes advancement to other services over time with the goal of getting patients to exercise independently. The time between routine clinic visits varies based on cancer treatment approach after surgery; therefore, it is important to re‐assess at routine clinic visits to ensure patients are getting what they need. For cases in which visits could be months apart, such as the time between the first postoperative visit and the visit 24 weeks after surgery, this workflow also addresses this need (Figure 1).

Table 1 provides details of the triaging tool decisions. The first questionnaire was the Patient‐Reported Outcomes Measurement Information System Physical Function Short Form 8b. This questionnaire consists of eight questions. 17 Based on established cutoff points to dictate functional decline, participants with Patient‐Reported Outcomes Measurement Information System T‐scores ≥51 are considered within normal limits, 18 and scores between 40 and 50 and <40 indicate mild‐to‐moderate and severe physical function, respectively. 18 The second questionnaire was the modified Godin questionnaire, which assessed average weekly exercise over the past month (times/week × minutes per session) through four questions: (1) strenuous aerobic exercise, (2) moderate aerobic exercise, (3) mild aerobic exercise, and (4) resistance training. 19 We determined whether an individual was meeting national physical activity guidelines with the following calculations: ([2 × times per week of strenuous exercise × average number of minutes each time of strenuous exercise] + [times per week of moderate exercise × average number of minutes each time of moderate exercise]) AND completing resistance training at least two times per week. Questionnaires were selected based on clinical validity in patients who had cancer and were used to establish cutoff points/interpretations to evaluate functional status and exercise engagement.

TABLE 1.

Comprehensive Oncology Rehabilitation and Exercise triaging tool decisions.

Pathway a PROMIS T‐score Meeting activity guidelines b
Yes No
PM&R <0 X
<40 X
Exercise 40–50 X
≥40 X
Exercise self‐management ≥51 X
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Abbreviations: PM&R, physical medicine and rehabilitation; PROMIS, Patient‐Reported Outcomes Measurement Information System.

a

PM&R and exercise are service pathways.

b

Participants completed a modified Godin questionnaire to determine national physical activity guideline adherence.

Focus groups to evaluate acceptability

Focus groups of study participants and clinical staff were conducted to determine the acceptability of the CORE clinical workflow algorithm. Focus groups were conducted virtually over Zoom using a semistructured guide and included from three to 12 individuals.

All participants enrolled in the trial and randomized to the CORE intervention were offered the opportunity to complete a focus group upon completion of their clinic visit 24 weeks after surgery. Because of challenges in getting patients to engage in focus groups, one of the focus groups was conducted after the first postoperative visit. This adaptation increased the number of participants willing to engage. The patient focus group guide is provided in Table S1.

One focus group was facilitated among clinic staff 1 year after implementation of the CORE algorithm. All members of the clinic team (e.g., breast surgical oncologists, nurses, medical assistants, support staff) were invited to this focus group by the study team. The staff focus group guide is provided in Table S2. Clinic staff who participated in this focus group were consented using a consent cover letter at the focus group.

Statistical analysis, feasibility and acceptability assessment

Demographic and clinical characteristics were obtained from the medical record and analyzed as descriptive statistics using R statistical software (version 4.1.2; R Core Team). Continuous variables are presented as medians and first and third quartiles or as frequencies and percentages. The p values were determined by using Wilcoxon rank‐sum tests. Categorical variables are presented as count data (percentage of the total, excluding missing values). Binary categorical variables were analyzed with the Fisher exact test. Categorical variables that had two or more categories were analyzed with the Pearson χ2 test.

Feasibility and acceptability metrics were developed by the investigative team in partnership with the study advisory board. The CORE clinical workflow algorithm was deemed feasible if ≥66% of participants randomized to CORE completed the triaging tool at the surgical consultation visit and, for those who were triaged to a service pathway (e.g., PM&R or exercise), if ≥50% completed their referral. At least 50% of the feedback within the identified themes/subthemes among study participant focus groups needed to be positive. These feasibility and acceptability metrics were developed by the investigative team in partnership with the study advisory board. Power and sample size calculations reveal that a sample size of 72 would result in this trial being 84% powered to be successful with an actual triaging tool completion rate of 75% and an actual referral completion rate of 60%.

Feedback from focus groups was assessed by audio‐recorded and professionally transcribed focus groups. Focus group data were coded and analyzed by developing a final codebook by the master coder (E.R.K.) and co‐coder (J.M.) using the qualitative research software ATLAS.ti version 23 (ATLAS.ti Scientific Software). The analysis of focus group feedback was based on the qualitative coding philosophy described by Crabtree and Miller, which uses an open‐coding approach in which codes are developed by identifying key themes and concepts that surfaced during the analysis process. 20 Main themes that emerged were grouped based on the evaluation of responses from study participants to corresponding questions during the semistructured focus group discussions. All transcripts underwent a double‐coding process to ensure intercoder reliability between the master coder and the co‐coder. The clinical staff transcript was summarized separately, and formal coding was not performed because there were no other comparable transcripts. The summary was then completed by the master coder and co‐coder. A final report capturing the study themes was compiled by the master coder with the help of another qualitative research analyst (P.G.), who contributed technical editing support.

In total, 15 study participants engaged in a patient focus group, and five clinicians participated in the clinic staff focus group. Four study participant focus groups were held remotely over Zoom between May 2022 and April 2023. The average number of patients with breast cancer per focus group was four. The clinical staff focus group was held remotely over Zoom and was conducted 1 year after the trial started, in March 2022. For all focus groups, the length ranged from 30 to 61 minutes, with an average duration of 47 minutes.

RESULTS

Participant characteristics

In total, 72 female patients with breast cancer were enrolled in this trial from March 2021 to March 2023. Eleven participants were considered screen failures because they started neoadjuvant chemotherapy; thus 40 participants were in the CORE arm and 21 were in the SOC arm. See Figure 2 for the Consolidated Standards for Reporting Trials diagram, see Table S3 for reasons for withdrawal (n = 10), and see Table 2 for participant characteristics. The median age of all participants was 58 years. Most participants were White (n = 46; 75%), non‐Hispanic (n = 55; 90%), and had stage I disease (n = 5;, 84%). The average time from initial surgical consultation to the date of surgery was 37 days. Statistically significant differences between groups for participant characteristics were not observed.

FIGURE 2.

FIGURE 2

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CONSORT diagram. Chemo indicates chemotherapy; CONSORT, Consolidated Standards for Reporting Trials; PM&R, physical medicine and rehabilitation; POWER, Personal Optimism with Exercise Recovery; SOC, standard of care.

TABLE 2.

Participant characteristics.

Median (first, third quartile) a
Characteristic CORE, n = 40 SOC, n = 21 Total, n = 61 p SMD
Age, years; n = 61 64 (50, 71) 51 (49, 60) 58 (50, 69) .10 .51
Height, cm; n = 59 165.1 (162.6, 170.2) 165.1 (162.6, 172.1) 165.1, (162.6, 165.1) .3 .34
Body mass, kg; n = 59 70.8 (66.7, 83.5) 70.3 (66.7, 84.4) 71.2 (65.8, 80.7) > .9 − .04
BMI, kg/m2; n = 59 25.7 (23.1, 30.0) 26.0 (24.5, 29.6) 26.0 (23.4, 29.9) 06 − .14
No. of patients (%)
Characteristic CORE, n = 40 SOC, n = 21 Total, n = 61 p SMD
Race
White 30 (75.0) 16 (76.0) 46 (75.0) > .9 .03
Unknown/not reported 10 (25.0) 5 (24.0) 15 (25.0)
Ethnicity
Hispanic 1 (2.5) 0 (0.0) 1 (1.6.0) .8 .31
Non‐Hispanic 35 (88.0) 20 (95.0) 55 (90.0)
Unknown/not reported 4 (10.0) 1 (4.8.0) 5 (8.2)
Cancer stage, n = 56
I 34 (97.0) 17 (81.0) 51 (91.0) .081 .56
II 1 (3.0) 2 (9.5) 3 (5.4)
III 0 (0.0) 1 (4.8) 1 (1.8)
IV 0 (0.0) 1 (4.8) 1 (1.8)
Postsurgery treatment type, n = 58 b
Chemotherapy 6 (16.0) 5 (24.0) 11 (19.0) .5 .19
Radiation 22 (59.0) 12 (57.0) 34 (59.0) .9 .05
Hormone therapy 33 (89.0) 18 (86.0) 51 (88.0) .7 .11
Immunotherapy 1 (2.7) 0 (0.0) 1 (1.7) > .9 .24
No. of treatments postsurgery, n = 58
Unimodal 11 (30.0) 6 (29.0) 17 (29.0) > .9 .03
Bimodal 18 (49.0) 10 (48.0) 28 (48.0) > .9 .02
Multimodal 5 (14.0) 3 (14.0) 8 (14.0) > .9 − .02
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Abbreviations: BMI, body mass index; CORE, Comprehensive Oncology Rehabilitation and Exercise; SMD, standardized mean difference; SOC, standard of care.

a

Numerical values represent the median (interquartile range) of the participant population within each group.

b

Some patients completed multiple therapies.

Feasibility

In total, 92.5% (n = 37) of participants randomized to CORE completed the triaging tool at their surgical consultation visit. Of those triaged to a service pathway (n = 29), 62.1% (n = 18) completed their referral (see Table S4). Thus CORE was feasible because >66% of patients completed the triaging tool at their surgical consultation visit, and >50% of these individuals completed their referral. Based on these data, this study was 90% powered to determine the feasibility of CORE in this patient population. At the first postoperative visit, 94.6% (n = 35) of patients with breast cancer completed the triaging tool. Of those triaged into a service pathway (n = 34), 67.7% (n = 23) completed their referral.

Acceptability: Patient focus group results

The codebook was created based on responses to specific focus group questions relating to one of three domains: assessment for triage, navigation in the algorithm, and satisfaction with the clinical workflow algorithm. Three main themes were identified: algorithm aspects, algorithm outcomes, and algorithm improvements. Within each theme, subthemes emerged. Below, we present a summary of the discussion within each subtheme. Tables S5–S7 present selected quotations of the most salient points from the focus groups. Greater than 50% of the feedback from focus groups was positive (75% within the algorithm aspects theme, 100% within the algorithm outcomes theme, and 50% within the algorithm improvements theme), deeming CORE acceptable in this patient population.

Theme 1: Algorithm aspects

Subtheme 1a: Clear referral process

Although most patients with breast cancer randomized to CORE thought that the referral process was without issue, some participants expressed confusion about the next steps they needed to take.

Subtheme 1b: Scheduling appointments

Among patients with breast cancer who were triaged to a service pathway, most were able to schedule their appointments in a timely manner. The few who identified challenges scheduling appointments attributed this to situational issues.

Subtheme 1c: Questionnaires

Most participants felt positive about the relevance of the questions asked in the triaging tool. Many felt comfortable answering the questions, with only some feeling that parts of the questionnaires were irrelevant. Most participants were content to complete the questionnaires at check‐in, although some would have liked to complete them before their clinic visit. Two participants thought some questions in the physical function questionnaire were unclear, and one felt overwhelmed by taking the questionnaire shortly after diagnosis.

Subtheme 1d: Challenges

Communication about referrals and problems with insurance costs were noted as challenges. Some were unclear about what to do for the service they were triaged to or why they were triaged to a specific pathway. Some reported issues with insurance costs and processes when services were billed to insurance.

Subtheme 1e: Facilitators

Participants praised the study team and other individuals within their health journeys. They also showed enthusiastic appreciation for the clinical workflow algorithm, especially when triaged to the exercise service pathway. Positive aspects of the exercise service included: flexibility, clear structure, and individualized exercise programming.

Theme 2: Algorithm outcomes

Subtheme 2a: Reduced symptoms

For most patients, the connection to exercise and rehabilitation services greatly helped address their symptoms after cancer treatment.

Subtheme 2b: Impact on activity/function

Participants reported that exercise and rehabilitation services throughout their care had a positive effect on their physical activity engagement and physical function, either by supporting the maintenance of an already active lifestyle despite cancer and its treatment and/or by improving function and activity.

Subtheme 2c: Plans for exercise

Several participants stated that they would like to continue exercising upon study completion. Participants mentioned that they: felt encouraged to get back into sports they had engaged in before their cancer diagnosis (e.g., volleyball, skiing, etc.), would like to try out new exercise activities (e.g., Pilates, tennis), or would continue newly learned exercises.

Subtheme 2d: Exercise needs

Many felt that they met or exceeded their exercise needs and goals. Participants complimented the expertise of the exercise service staff for pushing their exercise goals. Only some reported struggles in completing the prescriptions within the exercise or rehabilitation service pathway.

Theme 3: Algorithm improvements

The most common recommendations for improvement included: having someone do more follow‐up (e.g., a caseworker), printing handouts detailing the pathway they were triaged to and how/when they may move to another service within that pathway, and improving communication about the pathways in the algorithm.

Acceptability: Clinical staff focus group results

As mentioned previously, this focus group was conducted 1 year after implementation of the algorithm to facilitate immediate action and process improvements. Communication challenges were identified as a major actionable item. Therefore, the study team improved communication pathways among the team, with clinic teams, and among study participants. Pertaining to the triage tool, many clinicians talked about the smoothness of the process, agreeing that CORE did not affect normal clinical operations. In addition, administering the tool at patient check‐in was deemed appropriate, although some clinicians suggested that nurses could administer the tool. Although clinicians thought it was acceptable for staff to provide triage results and submit the referral, some stated that they were willing to do this and felt that it did not take much time or affect workflow.

DISCUSSION

This mixed‐methods, randomized controlled pilot trial tested a clinical workflow algorithm, named CORE, that integrated exercise and rehabilitation services as part of routine care from the time of diagnosis and throughout care for women newly diagnosed with stage I–III breast cancer who had plans for surgery as first‐line treatment. Among study participants who were randomized to CORE, 92.5% completed the triaging tool at their surgical consultation visit, and 62.0% completed their referral. Overwhelmingly positive feedback was noted from study participant focus groups, including 75% positive feedback on the algorithm aspects theme, 100% positive feedback within the algorithm outcomes theme, and 50% positive feedback on algorithm improvements. All rates surpassed the predetermined feasibility and acceptability metrics, indicating feasibility and acceptability of the CORE clinical workflow algorithm in this patient population.

Of the few exercise/rehabilitation models that exist, 12 , 13 , 14 , 21 , 22 , 23 various cancer types and stages have been included, although most included patients with breast cancer. 12 , 13 , 21 , 23 Consistent across models, but in contrast to CORE, the triaging timepoint only occurs once within the cancer care continuum. 12 , 14 , 21 , 22 In addition, an advantage of CORE is continuous assessment throughout cancer care at routine visits. Thus, to our knowledge, the CORE clinical workflow algorithm is the only model that aligns with the ASCO guidelines, highlighting the importance of exercise referrals during and throughout cancer treatment. 8

Another advantage of CORE is the conciseness of the triaging tool. Other models include longer, more complex questionnaires for triaging individuals into service pathways. 12 , 13 , 14 , 24 At the time of cancer diagnosis, individuals are often overwhelmed and are adjusting to life with a cancer diagnosis, underpinning the necessity to select short and uncomplicated questionnaires to include in the triage tool. Furthermore, the CORE triaging tool uses two well established, validated, and reliable questionnaires, along with established cutoff points that contributed to the determination of a service pathway, 25 which is unique to CORE and fulfills a gap in the current models available. Assessing physical function and activity levels with these two questionnaires provided an efficient method to triage patients with breast cancer into needed care pathways. This approach ensured that their needs were addressed at various stages of their care continuum without necessitating additional clearance during referral visits. Although our clinical team focus group revealed a notion to consider starting the algorithm after cancer surgery, as opposed to immediately after diagnosis, to decrease the initial strain on patients with breast cancer, most patients reported being positively affected by the inclusion of the CORE clinical workflow algorithm from the start of their breast cancer care despite these challenges. Patients reported that CORE made them feel supported by their care team from the onset of cancer diagnosis. In addition, the CORE clinical workflow algorithm aligns with guidance from ASCO and the American Cancer Society to engage patients in exercise as soon as possible after a cancer diagnosis. 26 , 27

A key strength of the current investigation was that this trial did not disrupt clinical workflow. We acknowledge that the presence of study coordinators in the clinic may have contributed to this smooth transition, but all steps from assessment to referral were performed by clinic staff. Other strengths consist of the following: use of short and validated questionnaires in the triaging tool; development of the algorithm in partnership with key stakeholders at our institution, resulting in a successful algorithm design compatible with various existing clinical structures; triaging at multiple timepoints across cancer care; and testing of the algorithm with a robust, mixed‐methods approach. Our trial is not without limitations, such as the inclusion of only one cancer type at a single center, a sample that was primarily non‐Hispanic White, and lack of an evaluation to determine why individuals in the CORE arm who received a referral did not complete their referral. Although different facilities and cancer treatment teams may have different workflows and resources, this algorithm can be adapted with minimal changes to accommodate various cancer types, care practices, and institutions. By chance, participants who were randomized to the CORE arm were older and had lower cancer stages compared with those randomized to the SOC arm. Because the analysis presented here is not a comparative‐effectiveness investigation, this imbalance does not affect the results. Future studies are recommended in more racially/ethnically diverse groups and in community clinics. If a community clinic does not have on‐site exercise and rehabilitation services, the site can still use CORE as a model and in tandem with the ACSM Moving Through Cancer program directory to identify local rehabilitation and exercise services. 28 Future research could also implement CORE among oncology clinics of all cancer types, stages, and treatment approaches.

CONCLUSION

The CORE clinical workflow algorithm is feasible, acceptable and addresses multiple gaps in pre‐existing models aimed at aligning exercise and rehabilitation services as part of routine cancer care. Findings from this trial support national efforts led by the ACSM to integrate exercise and rehabilitation services as part of routine cancer care. The CORE clinical workflow algorithm may serve as a model for other cancer centers nationwide.

AUTHOR CONTRIBUTIONS

Lea Haverbeck Simon: Writing—original draft; writing—review and editing. Carson Saviers‐Steiger: Investigation; data curation; writing—review and editing. Emily R. Dunston: Investigation; data curation; writing—review and editing. Patrick Galyean: Investigation; data curation; formal analysis; writing—review and editing. Elisabeth R. Kimball: Writing—review and editing; investigation; data curation; and formal analysis. Justine Mendez: Investigation; writing—review and editing; formal analysis; data curation. Susan L. Zickmund: Writing—review and editing; methodology; formal analysis; resources. Pamela A. Hansen: Investigation; writing—review and editing; resources. Cornelia M. Ulrich: Writing—review and editing; resources. Paul C. LaStayo: Writing—review and editing. David Steinberg: Writing—review and editing; resources. Christopher S. Noren: Resources; writing—review and editing. A'Lisha Finch: Resources; writing—review and editing. Leanne Seckinger: Writing—review and editing. Emma Braun: Formal analysis; writing—review and editing. Jonathan Chipman: Formal analysis; writing—review and editing. Kirstyn E. Brownson: Writing—review and editing; conceptualization; investigation. Sonal Oza: Conceptualization; writing—review and editing; investigation. Adriana M. Coletta: Conceptualization; investigation; funding acquisition; writing—review and editing; writing—original draft; project administration; supervision.

CONFLICT OF INTEREST STATEMENT

Kirstyn Brownson reports personal/consulting fees from ImpediMed Inc. outside the submitted work. The remaining authors disclosed no conflicts of interest.

Supporting information

Supplementary Material

CNCR-131-e35798-s001.docx (36.7KB, docx)

ACKNOWLEDGMENTS

The authors would thank the individuals who participated in this trial. We also like thank the breast surgical oncology clinic staff and the cancer exercise trainers within the Huntsman Cancer Institute's established, hospital‐based exercise oncology program. This trial was funded by the 5 for the Fight, a Qualtrics Inc.‐sponsored nonprofit organization.

Simon LH, Saviers‐Steiger C, Dunston ER, et al. Feasibility and acceptability of the Comprehensive Oncology Rehabilitation and Exercise (CORE) clinical workflow algorithm in patients with newly diagnosed stage I–III breast cancer who undergo surgery as first‐line treatment. Cancer. 2025;e35798. doi: 10.1002/cncr.35798

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material

CNCR-131-e35798-s001.docx (36.7KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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