Implementing the Personalised Exercise Rehabilitation in Cancer Survivorship (PERCS) Triage and Referral System in Ireland: Protocol for a Qualitative Stakeholder Study

Introduction

Over 200,000 people in Ireland are currently living with and beyond cancer, and this number is projected to rise significantly as 10-year survival rates continue to improve, in line with European estimates (Lawler et al., 2023). With survivorship increasing, there is growing recognition of the importance of addressing the longer-term health and quality-of-life needs of this population. The National Cancer Strategy 2017–2026 (Department of Health, 2017) explicitly commits to enhancing quality of life for survivors, recognising exercise rehabilitation as a key component of survivorship care.

Cancer treatment can result in a range of physical and psychosocial sequelae, including fatigue, muscle weakness, reduced cardiopulmonary fitness, anxiety, and depression, many of which are amenable to targeted exercise interventions (Campbell et al., 2019; Courneya et al., 2025). An estimated 60–90% of individuals affected by cancer have at least one specialised rehabilitation need (Pergolotti et al., 2015), which may include cancer-related comorbidities or impairments such as weakness, cachexia, loss of balance, lymphoedema, or pain. There is robust international evidence supporting the role of exercise in improving physical, psychological, and disease-related outcomes for people living with and beyond cancer but it is important that exercise support is adaptable to individual needs. Patients with significant impairments may benefit from hospital- or primary-care-based rehabilitation programmes delivered by rehabilitation specialists, while physically inactive patients without impairments may be well served by community-based exercise programmes delivered by physiotherapists or exercise specialists (Coletta et al., 2020; Schmitz et al., 2021).

To allow translation of exercise guidelines into practice, coordinated systems are needed to direct patients to the appropriate level of care, balancing clinical need with service capacity. This typically involves collaborative models that span hospital and community settings. Internationally, stepped-care approaches and triage and referral systems have been proposed to guide decision-making and streamline access to appropriate supports (Capozzi et al., 2023; Covington et al., 2021; Dennett et al., 2020; Mina et al., 2018; Schmitz et al., 2024; Stout et al., 2020). These models generally recognise a spectrum of complexity arising from comorbidities and treatment side-effects, incorporate screening assessments to identify risks requiring medical or rehabilitation oversight and recommend tailored referrals to supervised rehabilitation, community exercise programmes, or self-management supports. While some of these frameworks are underpinned by formal triage processes (Capozzi et al., 2023; Covington et al., 2021; Stout et al., 2020), most remain theoretical. Only a limited number have been tested for feasibility and implementation in real-world settings, demonstrating positive outcomes (Capozzi et al., 2023; Schmitz et al., 2024). These models also typically operate within health systems such as those in the United States, Canada, and Australia where access to cancer physiatry, clinical exercise physiologists, and tiered rehabilitation services are well established.

In contrast, the vision of every cancer patient in Ireland having access to exercise during and after treatment is not yet being realised. Survivors often face multiple barriers to engagement, including a lack of professional guidance, unclear referral pathways, and limited local service availability (Brennan et al., 2022; Nadler et al., 2017; Riordan et al., 2025). Ireland does not currently have a recognised cancer physiatry discipline, and clinical exercise physiologists are not formally integrated into the healthcare system. Rehabilitation services remain unevenly distributed and poorly resourced, contributing to inconsistent access to appropriate support.

To address this gap, the research team developed the Personalised Exercise Rehabilitation in Cancer Survivorship (PERCS) system, a triage and referral model tailored to the Irish healthcare context. The system assesses cancer survivors’ exercise needs and guides referral to one of three appropriate pathways: (1) independent exercise with provision of online resources, (2) community-based exercise programmes, or (3) physiotherapist-led rehabilitation.

PERCS 1.0, funded by the Irish Cancer Society, tested the feasibility and acceptability of this system through a physiotherapy-led clinic for survivors of cancer treated during the COVID-19 pandemic. Results were highly encouraging:

•   Over 90% of participants required support to become physically active (Brennan et al., 2024)

•   67% were referred to community exercise programmes (Brennan et al., 2024)

•   Adherence to physical activity guidelines improved for both aerobic and resistance exercise at 12 weeks (Brennan et al., 2024)

•   Participants reported high satisfaction with the personalised assessment and referral approach (Brennan et al., 2025)

These findings provided critical proof-of-concept for the PERCS triage and referral approach, demonstrating real-world feasibility and positive patient impact within the Irish setting. PERCS 2.0 seeks to build on this work by shifting the focus from local feasibility to national implementation through the exploration of and response to the contextual factors influencing the scaling of the PERCS system across the Irish healthcare landscape.

Aims and objectives

The aim of this study is to inform the national implementation of the PERCS triage and referral system by understanding key contextual factors influencing its uptake and identifying strategies to support its successful delivery across the Irish healthcare system.

To achieve this aim, the objectives are:

•   To explore the contextual factors influencing the implementation of the PERCS triage and referral system nationally and

•   To identify and prioritise the implementation strategies that can address these contextual factors

These aims will be achieved using the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis and the Expert Recommendations for Implementing Change (ERIC) taxonomy to map factors to potential strategies.

Methods

Conclusion

This study aims to generate in-depth, contextually relevant information which can feed into the implementation of the PERCS triage and referral system for exercise rehabilitation in cancer survivorship across Ireland. By engaging with a broad range of stakeholders and applying the CFIR framework within a rigorous qualitative methodology, the research will identify key barriers, facilitators, and contextual considerations that influence implementation. These findings will inform the development of targeted, stakeholder-informed strategies to support the national scale-up of PERCS and contribute to broader efforts to integrate exercise into routine cancer care. The study will provide a valuable platform for future implementation planning, policy development, and service design of cancer rehabilitation.