Agz Lemanska first trained as a pharmacist and completed her training graduating with an MSc in Pharmacy in 2005. She then studied for her PhD in Statistics and Machine Learning at the Centre for Chemometrics, University of Bristol (scholarship funded by GlaxoSmithKline). She is now working as a Senior Lecturer in the School of Health Sciences, Faculty of Health and Medical Sciences and is involved in teaching and research activities within the School.
Areas of specialism
University roles and responsibilities
- Lead for International, School of Health Sciences
- Lead for Faculty Staff Mobility, Faculty of Health and Medical Sciences
- Erasmus Coordinator, School of Health Sciences
Affiliations and memberships
Business, industry and community links
Agz Lemanska is Lecturer in Integrated Care at School of Health Sciences, University of Surrey. She is also Lead for International and Erasmus coordinator at the School of Health Sciences.
Her main research interests are in the area of Big Data analytics and Data Linkage and its applications to healthy ageing, long-term health, multimorbidity and cancer survivorship. Agz is a Pharmacist and a Statistician. She combines her clinical and statistical expertise to deliver research projects with a vision to improve long-term health of the population.
- Big Data analytics
- Data linkage
- Routinely collected Primary and Secondary Care data
- Randomised Controlled Trials (supplementation with routinely collected data)
- Cancer survivorship
- Long-term conditions
- Healthy ageing
- Integrated Care
PI, Jun 2017 – ongoing
Retrospective cohort, case control study to analyse and compare to healthy controls, primary care records of prostate cancer patients treated with hormone therapy (HT). Primary care database extraction.
PI, May 2016 – December 2018
Data linkage. In this project we extracted primary care (GP) records for patients enrolled in CHHiP randomised controlled trial (RCT) to investigate the effect of cardiovascular and diabetes comorbidities and prescription medications on radiotherapy-related health-outcomes of patients.
CI, Mar 2014 – Nov 2017
In this project we developed and tested in 9 community pharmacies an innovative community pharmacy lifestyle intervention to support men after prostate cancer. This project was funded by Movember Foundation and PCUK as part fo the global TrueNTH initiative.
PI, Jan 2013 – Oct 2017
Published predictive risk modelling of Patient Reported Outcomes to investigate risk factors for long-term radiotherapy toxicity.
BSc (Hons) Project and Dissertation supervision
PG, Independent prescribing (V300)
- Calculation skills
- Medicines management
- Prescribing skills
PG, Independent prespring (V100)
- Medicines management
- Calculation skills
PG, Pain management
- Pharmacology of pain
PG, Systemic Anti-cancer Treatment
- Pharmacology of chemotherapy drugs
UG, Physician associate programme
- Medicines management
- Calculation skills
UG, Nursing programmes
- Quantitative research skills
- Understanding research
- Long-term conditions management
- Medicines management
UG, Paramedics programme
- Pharmacology of paramedics drugs
- Advanced use of Excel, Principal Components Analysis for Pattern Recognition workshop
- Chemometrics and Data Quality workshop
Background: The COVID-19 pandemic has resulted in unprecedented impact on the day to day lives of people, with several features potentially adversely affecting mental health. There is growing evidence of the size of the impact of COVID-19 on mental health, but much of this is from ongoing population surveys using validated mental health scores. Objective: This study investigated the impact of the pandemic and control measures on mental health conditions presenting to a spectrum of national healthcare services monitored using real-time syndromic surveillance in England. Methods: We conducted a retrospective observational descriptive study of mental health presentations (those calling the national medical helpline, NHS 111, consulting general practitioners in and out-of-hours, calling ambulance services and attending emergency departments) between 1 January 2019 to 30 September 2020. Estimates for the impact of lockdown measures were provided using an interrupted time series analysis. Results: Mental health presentations showed a marked decrease during the early stages of the pandemic. Post-lockdown, attendances for mental health conditions reached higher than pre-pandemic levels across most systems; a rise of 10% compared to expected for NHS 111 and 21% for GP out-of-hours whilst the number of consultations to in-hours GPs was 13% lower compared to the same time last year. Increases were observed in calls to NHS 111 for sleep problems. Conclusions: These analyses showed marked changes in the healthcare attendances and prescribing for common mental health issues, across a spectrum of healthcare provision, with some of these changes persisting. The reasons for such changes are likely to be complex and multifactorial. The impact of the pandemic on mental health may not be fully understood for some time, and therefore these syndromic indicators should continue to be monitored.
To report patient activation, which is the knowledge, skills, and confidence in self-managing health conditions, and patient-reported outcomes of men after prostate cancer treatment from a community pharmacy lifestyle intervention. The 3-month lifestyle intervention was delivered to 116 men in nine community pharmacies in the UK. Patient Activation Measure (PAM) was assessed at baseline, 3 and 6 months. Prostate cancer-related function and quality of life were assessed using the European Prostate Cancer Index Composite (EPIC-26) and EuroQOL 5-dimension 5-level (EQ5D-5L) questionnaires at baseline and 6 months. Lifestyle assessments included Mediterranean Diet Adherence Screener (MEDAS) at baseline, 3 and 6 months and Godin Leisure Time Exercise Questionnaire (GLTEQ) at baseline and 3 months. PAM score increased from 62 [95% CI 59-65] at baseline to 66 [64-69] after the intervention (p = 0.001) and remained higher at 6 months (p = 0.008). Scores for all the EPIC-26 domains (urinary, bowel and hormonal) were high at both assessments, indicating good function (between 74 [70-78] and 89 [86-91]), except sexual domain, where scores were much lower (21 [17-25] at baseline, increasing to 24 [20-28] at 6 months (p = 0.012)). In EQ5D-5L, 3% of men [1-9] reported self-care problems, while 50% [41-60] reported pain and discomfort, and no significant changes over time. Men who received androgen deprivation therapy, compared with those who did not, reported higher (better) urinary incontinence scores (p
The effect of the 2020 pandemic, and of the national measures introduced to control it, is not yet fully understood. The aim of this study was to investigate how different types of primary care data can help quantify the effect of the coronavirus disease (COVID-19) crisis on mental health. A retrospective cohort study investigated changes in weekly counts of mental health consultations and prescriptions. The data were extracted from one the UK’s largest primary care databases between January 1 st 2015 and October 31st 2020 (end of follow-up). The 2020 trends were compared to the 2015-19 average with 95% confidence intervals using longitudinal plots and analysis of covariance (ANCOVA). A total number of 504 practices (7,057,447 patients) contributed data. During the period of national restrictions, on average, there were 31% (3957 ± 269, p < 0.001) fewer events and 6% (4878 ± 1108, p < 0.001) more prescriptions per week as compared to the 2015-19 average. The number of events was recovering, increasing by 75 (± 29, p = 0.012) per week. Prescriptions returned to the 2015-19 levels by the end of the study (p = 0.854). The significant reduction in the number of consultations represents part of the crisis. Future service planning and quality improvements are needed to reduce the negative effect on health and healthcare.
Background: Education literature worldwide is replete with studies evaluating the effectiveness of Multiple Mini Interviews (MMIs) in admissions to medicine but
Background: Patients receiving cancer treatment often have one or more co-morbid conditions that are treated pharmacologically. Co-morbidities are recorded in clinical trials usually only at baseline. However, co-morbidities evolve and new ones emerge during cancer treatment. The interaction between multi-morbidity and cancer recovery is significant but poorly understood. Purpose: To investigate the effect of co-morbidities (e.g. cardiovascular and diabetes) and medications (e.g. statins, antihypertensives, metformin) on radiotherapy-related toxicity and long-term symptoms in order to identify potential risk factors. The possible protective effect of medications such as statins or antihypertensives in reducing radiotherapy-related toxicity will also be explored. Methods: Two datasets will be linked. 1) CHHiP (Conventional or Hypofractionated High Dose Intensity Modulated Radiotherapy for Prostate Cancer) randomised control trial. CHHiP contains pelvic symptoms and radiation-related toxicity reported by patients and clinicians. 2) GP (General Practice) data from RCGP RSC (Royal College of General Practitioners Research and Surveillance Centre). The GP records of CHHiP patients will be extracted, including cardiovascular co-morbidities, diabetes and prescription medications. Statistical analysis of the combined dataset will be performed in order to investigate the effect. Conclusions: Linking two sources of healthcare data is an exciting area of big healthcare data research. With limited data in clinical trials (not all clinical trials collect information on co-morbidities or medications) and limited lengths of follow-up, linking different sources of information is increasingly needed to investigate long-term outcomes. With increasing pressures to collect detailed information in clinical trials (e.g. co-morbidities, medications), linkage to routinely collected data offers the potential to support efficient conduct of clinical trials.
Background: Universities in the United Kingdom (UK) are required to incorporate values based recruitment (VBR) into their healthcare student selection processes. This reflects an international drive to strengthen the quality of healthcare service provision. This paper presents novel findings in relation to the reliability and predictive validity of multiple mini interviews (MMIs); one approach to VBR widely being employed by universities. Objectives: To examine the reliability (internal consistency) and predictive validity of MMIs using end of Year One practice outcomes of under-graduate pre-registration adult, child, mental health nursing, midwifery and paramedic practice students. Design: Cross-discipline evaluation study. Setting: One university in the United Kingdom. Participants: Data were collected in two streams: applicants to A) The September 2014 and 2015 Midwifery Studies programmes; B) September 2015 adult; Child and Mental Health Nursing and Paramedic Practice programmes. Fifty-seven midwifery students commenced their programme in 2014 and 69 in 2015; 47 and 54 agreed to participate and completed Year One respectively. 333 healthcare students commenced their programmes in September 2015. Of these, 281 agreed to participate and completed their first year (180 adult, 33 child and 34 mental health nursing and 34 paramedic practice students). Methods: Stream A featured a seven station four-minute model with one interviewer at each station and in Stream B a six station model was employed. Cronbach’s alpha was used to assess MMI station internal consistency and Pearson’s moment correlation co-efficient to explore associations between participants’ admission MMI score and end of Year one clinical practice outcomes (OSCE and mentor grading). Results: Stream A: Significant correlations are reported between midwifery applicant’s MMI scores and end of Year One practice outcomes. A multivariate linear regression model demonstrated that MMI score significantly predicted end of Year One practice outcomes controlling for age and academic entry level: coefficients 0.195 (p = 0.002) and 0.116 (p = 0.002) for OSCE and mentor grading respectively. In Stream B no significant correlations were found between MMI score and practice outcomes measured by mentor grading. Internal consistency for each MMI station was ‘excellent’ with values ranging from 0.966–0.974 across Streams A and B. Conclusion: This novel, cross-discipline study shows that MMIs are reliable VBR tools which have predictive validity when a seven station model is used. These data are important given the current international use of different MMI models in healthcare student selection processes.
Purpose: To identify symptom clusters and predisposing factors associated with long-term symptoms and health-related quality of life (HRQOL) following radiotherapy in men with prostate cancer. Methods: Patient-reported outcomes (PROs) data from the Medical Research Council RT01 radiotherapy with neoadjuvant androgen deprivation therapy (ADT) trial of 843 patients were used. PROs were collected over 5 years with the University of California, Los Angeles Prostate Cancer Index (UCLA-PCI) and the 36-Item Short-Form Health Survey (SF-36). Symptom clusters were explored using hierarchical cluster analysis (HCA). The association of treatment dose, baseline patient characteristics and early symptom clusters with the change in severity of PROs over three years was investigated with multivariate linear mixed effects models. Results: Seven symptom clusters of three or more symptoms were identified. The clusters were stable over time. The longitudinal profiles of symptom clusters showed the onset of acute symptoms during treatment for all symptom clusters and significant recovery by six months. Some clusters such as Physical Health and Sexual Function were adversely affected more than others by ADT, and were less likely to return to pre-treatment levels over time. Older age was significantly associated with decreased long-term Physical Function, Physical Health and Sexual Function (p
Background Randomised controlled trials (RCTs) are the gold standard for evidence-based practice. However, RCTs can have limitations. For example, translation of findings into practice can be limited by design features, such as inclusion criteria, not accurately reflecting clinical populations. In addition, it is expensive to recruit and follow-up participants in RCTs. Linkage with routinely collected data could offer a cost-effective way to enhance the conduct and generalisability of RCTs. The aim of this study is to investigate how primary care data can support RCTs. Methods Secondary analysis following linkage of two datasets: 1) multicentre CHHiP radiotherapy trial (ISRCTN97182923) and 2) primary care database from the Royal College of General Practitioners Research and Surveillance Centre. Comorbidities and medications recorded in CHHiP at baseline, and radiotherapy-related toxicity recorded in CHHiP over time were compared with primary care records. The association of comorbidities and medications with toxicity was analysed with mixed-effects logistic regression. Results Primary care records were extracted for 106 out of 2811 CHHiP participants recruited from sites in England (median age 70, range 44 to 82). Complementary information included longitudinal body mass index, blood pressure and cholesterol, as well as baseline smoking and alcohol usage but was limited by the considerable missing data. In the linked sample, 9 (8%) participants were recorded in CHHiP as having a history of diabetes and 38 (36%) hypertension, whereas primary care records indicated incidence prior to trial entry of 11 (10%) and 40 (38%) respectively. Concomitant medications were not collected in CHHiP but available in primary care records. This indicated that 44 (41.5%) men took aspirin, 65 (61.3%) statins, 14 (13.2%) metformin and 46 (43.4%) phosphodiesterase-5-inhibitors at some point before or after trial entry. Conclusions We provide a set of recommendations on linkage and supplementation of trials. Data recorded in primary care are a rich resource and linkage could provide near real-time information to supplement trials and an efficient and cost-effective mechanism for long-term follow-up. In addition, standardised primary care data extracts could form part of RCT recruitment and conduct. However, this is at present limited by the variable quality and fragmentation of primary care data.
Background Assessing fitness and promoting regular physical activity can improve health outcomes and early recovery in prostate cancer. This is however, underutilised in clinical practice. The cardiopulmonary exercise test (CPET) is increasingly being used pre-treatment to measure aerobic capacity and peak oxygen consumption (VO2peak - a gold standard in cardiopulmonary fitness assessment). However, CPET requires expensive equipment and may not always be appropriate. The Siconolfi step test (SST) is simpler and cheaper, and could provide an alternative. The aim of this study was to evaluate the validity and reliability of SST for predicting cardiopulmonary fitness in men with prostate cancer. Men were recruited to this two-centre study (Surrey and Newcastle, United Kingdom) after treatment for locally advanced prostate cancer. They had one or more of three risk factors: elevated blood pressure, overweight (BMI ˃ 25), or androgen deprivation therapy (ADT). Cardiopulmonary fitness was measured using SST and cycle ergometry CPET, at two visits three months apart. The validity of SST was assessed by comparing it to CPET. The VO2peak predicted from SST was compared to the VO2peak directly measured with CPET. The reliability of SST was assessed by comparing repeated measures. Bland-Altman analysis was used to derive limits of agreement in validity and reliability analysis. Results Sixty-six men provided data for both SST and CPET. These data were used for validity analysis. 56 men provided SST data on both visits. These data were used for reliability analysis. SST provided valid prediction of the cardiopulmonary fitness in men ˃ 60 years old. The average difference between CPET and SST was 0.64 ml/kg/min with non-significant positive bias towards CPET (P = 0.217). Bland-Altman 95% limits of agreement of SST with CPET were ± 7.62 ml/kg/min. SST was reliable across the whole age range. Predicted VO2peak was on average 0.53 ml/kg/min higher at Visit 2 than at Visit 1 (P = 0.181). Bland-Altman 95% limits of agreement between repeated SST measures were ± 5.84 ml/kg/min. Conclusions SST provides a valid and reliable alternative to CPET for the assessment of cardiopulmonary fitness in older men with prostate cancer. Caution is advised when assessing men 60 years old or younger because the VO2peak predicted with SST was significantly lower than that measured with CPET.
Saliva is an easy to obtain bodily fluid that is specific to the oral environment. It can be used for metabolomic studies as it is representative of the overall wellbeing of an organism, as well as mouth health and bacterial flora. The metabolomic structure of saliva varies greatly depending on the bacteria present in the mouth as they produce a range of metabolites. In this study we have investigated the metabolomic profiles of human saliva that were obtained using 1H NMR (nuclear magnetic resonance) analysis. 48 samples of saliva were collected from 16 healthy subjects over 3 days. Each sample was split in two and the first half treated with an oral rinse, while the second was left untreated as a control sample. The 96 1H NMR metabolomic profiles obtained in the dataset are affected by three factors, namely 16 subjects, 3 sampling days and 2 treatments. These three factors contribute to the total variation in the dataset. When analysing datasets from saliva using traditional methods such as PCA (principal component analysis), the overall variance is dominated by subjects' contributions, and we cannot see trends that would highlight the effect of specific factors such as oral rinse. In order to identify these trends, we used methods such as MSCA (multilevel simultaneous component analysis) and ASCA (ANOVA simultaneous component analysis), that provide variance splits according to the experimental factors, so that we could look at the particular effect of treatment on saliva. The analysis of the treatment effect was enhanced, as it was isolated from the overall variance and assessed without confounding factors. © 2011 Springer Science+Business Media, LLC.
Objectives: To assess the feasibility and acceptability of a community pharmacy lifestyle intervention to improve physical activity and cardiovascular health of men with prostate cancer. To refine the intervention. Design: Phase II feasibility study of a complex intervention. Setting: Nine community pharmacies in the UK. Intervention: Community pharmacy teams were trained to deliver a health assessment including fitness, strength and anthropometric measures. A computer algorithm generated a personalised lifestyle prescription for a homebased programme accompanied by supporting resources. The health assessment was repeated 12 weeks later and support phone calls were provided at weeks 1 and 6. Participants: 116 men who completed treatment for prostate cancer. Outcome measures: The feasibility and acceptability of the intervention and the delivery model were assessed by evaluating study processes (rate of participant recruitment, consent, retention and adverse events), by analysing delivery data and semi-structured interviews with participants and by focus groups with pharmacy teams. Physical activity (measured with accelerometry at baseline, 3 and 6 months) and patient reported outcomes (activation, dietary intake and quality of life) were evaluated. Change in physical activity was used to inform the sample size calculations for a future trial. Results: Out of 403 invited men, 172 (43%) responded and 116 (29%) participated. Of these, 99 (85%) completed the intervention and 88 (76%) completed the 6-month follow-up (attrition 24%). Certain components of the intervention were feasible and acceptable (eg, community pharmacy delivery), while others were more challenging (eg, fitness assessment) and will be refined for future studies. By 3 months, moderate to vigorous physical activity increased on average by 34 min (95% CI 6 to 62, p=0.018), but this was not sustained over 6 months. Conclusions: The community pharmacy intervention was feasible and acceptable. Results are encouraging and warrant a definitive trial to assess the effectiveness of the refined intervention.
Purpose: To investigate the role of symptom clusters in the analysis and utilisation of Patient-Reported Outcome Measures (PROMs) for data modelling and clinical practice. To compare symptom clusters with scales, and explore their value in PROMs interpretation and symptom management. Methods: A dataset called RT01 (ISCRTN47772397) of 843 prostate cancer patients was used. PROMs were reported with the University of California, Los Angeles Prostate Cancer Index (UCLA-PCI). Symptom clusters were explored with hierarchical cluster analysis (HCA) and average linkage method (correlation >0.6). The reliability of the Urinary Function Scale was evaluated with Cronbach's Alpha. The strength of the relationship between the items was investigated with Spearman's correlation. Predictive accuracy of the clusters was compared to the scales by receiver operating characteristic (ROC) analysis. Presence of urinary symptoms at 3 years measured with the Late Effects on Normal Tissue: Subjective, Objective, Management tool (LENT/SOM) was an endpoint. Results: Two symptom clusters were identified (Urinary Cluster and Sexual Cluster). The grouping of symptom clusters was different than UCLA-PCI Scales. Two items of the Urinary Function Scales (“Number of pads” and “Urinary leak interfering with sex”) were excluded from the Urinary Cluster. The correlation with the other items in the scale ranged from 0.20-0.21 and 0.31-0.39 respectively. Cronbach's Alpha showed low correlation of those items with the Urinary Function Scale (0.14-0.36 and 0.33-0.44 respectively). All Urinary Function Scale items were subject to a ceiling effect. Clusters had better predictive accuracy, AUC = 0.70-0.65, while scales AUC = 0.67-0.61. Conclusion: This study adds to the knowledge on how cluster analysis can be applied for the interpretation and utilisation of PROMs. We conclude that multiple-item scales should be evaluated and that symptom clusters provide an adaptive and study specific approach for modelling and interpretation of PROMs.
Patient reported outcome measures (PROMs) are increasingly being used in research to explore experiences of cancer survivors. Techniques to predict symptoms, with the aim of providing triage care, rely on the ability to analyse trends in symptoms or quality of life and at present are limited. The secondary analysis in this study uses a statistical method involving the application of autoregression (AR) to PROMs in order to predict symptom intensity following radiotherapy, and to explore its feasibility as an analytical tool. The technique is demonstrated using an existing dataset of 94 prostate cancer patients who completed a validated battery of PROMs over time. In addition the relationship between symptoms was investigated and symptom clusters were identified to determine their value in assisting predictive modeling. Three symptom clusters, namely urinary, gastrointestinal and emotional were identified. The study indicates that incorporating symptom clustering into predictive modeling helps to identify the most informative predictor variables. The analysis also showed that the degree of rise of symptom intensity during radiotherapy has the ability to predict later radiotherapy-related symptoms. The method was most successful for the prediction of urinary and gastrointestinal symptoms. Quantitative or qualitative prediction was possible on different symptoms. The application of this technique to predict radiotherapy outcomes could lead to increased use of PROMs within clinical practice. This in turn would contribute to improvements in both patient care after radiotherapy and also strategies to prevent side effects. In order to further evaluate the predictive ability of the approach, the analysis of a larger dataset with a longer follow up was identified as the next step.
The purpose of this study was to compare fitness parameters and cardiovascular disease risk of older and younger men with prostate cancer (PCa) and explore how men's fitness scores compared to normative age values. 83 men were recruited post-treatment and undertook a cardiopulmonary exercise test (CPET), sit-to-stand, step-and-grip strength tests and provided blood samples for serum lipids and HbA1c. We calculated waist-to-hip ratio, cardiovascular risk (QRISK2), Charlson comorbidity index (CCI) and Godin leisure-time exercise questionnaire [GLTEQ]. Age-group comparisons were made using normative data. Men > 75 years, had lower cardiopulmonary fitness, as measured by VO2 Peak (ml/kg/min) 15.8 + 3.8 p < 0.001, and lower grip strength(28.6+5.2 kg p < 0.001) than younger men. BMI ≥30kg/m2 and higher blood pressure all contributed to a QRisk2 score indicative of 20% chance of cardiovascular risk within 10 years (mean: 36.9–6.1) p < 0.001. Age, BMI and perceived physical activity were significantly associated with lower cardiopulmonary fitness. Men with PCa > 75 years had more cardiovascular risk factors compared to normative standards for men of their age. Although ADT was more frequent in older men, this was not found to be associated with cardiopulmonary fitness, but obesity and low levels of physical activity were. Secondary prevention should be addressed in men with PCa to improve men's overall health.
Although routine healthcare data are not collected for research, they are increasingly used in epidemiology and are key real-world evidence for improving healthcare. This study presents a method to identify prostate cancer cases from a large English primary care database. 19,619 (1.3%) men had a code for prostate cancer diagnosis. Codes for medium and high Gleason grading enabled identification of additional 94 (0.5%) cases. Many studies do not report codes used to identify patients, and if published, the lists of codes differ from study to study. This can lead to poor research reproducibility and hinder validation. This work demonstrates that carefully developed comprehensive lists of clinical codes can be used to identify prostate cancer; and that approaches that do not solely rely on clinical codes such as ontologies or data linkage should also be considered.
Objective It is well established that exercise and lifestyle behaviours improve men's health outcomes from prostate cancer. With 3.8 million men living with the disease worldwide, the challenge is creating accessible intervention approaches that lead to sustainable lifestyle changes. We carried out a phase II feasibility study of a lifestyle intervention delivered by nine community pharmacies in the United Kingdom to inform a larger efficacy study. Qualitative interviews explored how men experienced the intervention, and these data are presented here. Methods Community pharmacies delivered a multicomponent lifestyle intervention to 116 men with prostate cancer. The intervention included a health, strength, and fitness assessment, immediate feedback, lifestyle prescription with telephone support, and reassessment 12 weeks later. Three months after receiving the intervention, 33 participants took part in semistructured telephone interviews. Results Our framework analysis identified how a teachable moment can be created by a community pharmacy intervention. There was evidence of this when men's self‐perception was challenged and coupled to a positive interaction with a pharmacist. Our findings highlight the social context of behaviour change with men identifying how their lifestyle choices were negotiated within their household. There was a ripple effect as lifestyle behaviours made a positive impact on friends and family. Conclusions The teachable moment is not a serendipitous opportunity but can be created by an intervention. Our study adds insight into how community pharmacists can support cancer survivors to make positive lifestyle behaviour changes and suggests a role for doing rather than just telling.