further modify the risk of adenoma recurrence. Data suggest that physical activity equivalent to 30 minutes of walking/day is adequate to reduce risk of developing colon cancer, while a higher exercise dose (60 min/day) may be necessary to reduce colon cancer recurrence and mortality. As physical activity interventions often struggle to achieve the intervention target dose, determining whether a higher dose is feasible is an important first step before broader dissemination or implementation of physical activity programs to prevent colon adenomas and cancer. The overall objective of this study was to evaluate the feasibility of a pilot intervention to deliver two doses of physical activity delivered through an existing evidence-based walking intervention paradigm to individuals who have had colon polyps and are thus at increased risk for colon cancer. The First Step Program (FSP, also published as Manpo-Kei) is an evidence and theoretically- based two phase intervention that aims to promote uptake of and adherence to physical activity, specifically walking, using pedom- eters [14–22]. FSP addresses self-efficacy, outcome expectations and social support in line with social cognitive theory and moves participants through the phases of the Transtheoretical Model [23]. The intervention focuses on home-based moderate intensity walking with regular contact with study staff. FSP has repeatedly been shown to successfully increase physical activity in patient populations [16,24], and in community settings [15,22] Further- more, the intervention successfully promoted a sustained increase in steps/day when implemented in ‘‘real world’’ settings, using existing diabetes educators and peer leaders [14] and in a community setting [21], indicating the intervention is effective and efficacious. Pedometers are easy to use, relatively low cost, reliable and accurate [25]. The combination of the high frequency of walking as a physical activity and the comparatively low cost of pedometers has made them a popular tool for population-based research, both as a motivational and measurement device. Pedometer-based interventions typically focus on a 10,000 steps per day goal, which has support in clinical and monitored populations, [1,2,3] A review of 32 observational and intervention studies suggests that typical daily step counts range from: (1) 7–13,000 steps per day for healthy younger adults; (2) 6–8,500 steps per day for healthy older adults; and (3) 3,500–5,000 steps per day for sedentary individuals and those with disabilities of chronic illness [26]. These findings were corroborated in a study of urban African American adults [27], but data on other racial/ethnic groups has not yet been reported. Current research suggests step counts in the range of 3000–4000 steps are accumulated during 30-minutes of walking. [4,5] Thus, for a healthy older adult, 10,000 steps would be accumulated through usual daily activities plus a 30-minute walk, making the 10,000 steps/day recommendation parallel to the physical activity guidelines [6] Reviews of walking interventions conclude that the use of pedometers [28] and telephone prompts [29], as is done in the second phase of FSP, successfully increase walking [30]. This study tested the feasibility of a pilot physical activity intervention designed for individuals with a recently resected colon adenoma. The focus of the study was on the development of an intervention that would require minimal face-to-face contact time to potentially improve future sustainability in clinical practice yet still initiate physical activity behavior change. Methods In this study, we refined and pilot tested an evidence-based intervention to promote walking among individuals with a previous colon adenoma. Physical Activity in Patients with Colon Adenomas The Step Down Colon Cancer (SDCC) pilot tested an evidence- based intervention to promote walking, using pedometers, among individuals with a previous colon polyp (Protocol S1, Checklist S1). SDCC is a 12-week two-arm randomized controlled trial program prescribing two different doses (30 minutes vs 60 minutes) of walking-based physical activity [17,31]. This study builds on previous physical activity interventions with cancer outcomes where 12 week interventions are common [32–36]. Recruitment To identify eligible patients, staff in the hospital-based gastroenterology practice reviewed practice records to identify individuals potentially meeting preliminary eligibility criteria. Study information was mailed to 399 men and women who underwent resection of a colon adenoma during a routine screening colonoscopy at Siteman Cancer Center. These individ- uals received a letter from their gastroenterologist inviting them to participate in the study. Individuals were then contacted by phone to confirm eligibility if interested. Eligibility criteria included individuals between the ages of 50 and 80 with no personal cancer history who were diagnosed with adenomatous polyp upon screening colonoscopy in previous 6 months and had no contraindications to beginning an exercise program, no previous diagnosis of diabetes, familial polyposis syndromes, ulcerative colitis or Crohn’s disease. Individuals were ineligible if they reported 30 or more minutes of moderate intensity physical activity 5 or more days per week or 20 or more minutes of vigorous intensity physical activity 3 or more days per week using the Behavioral Risk Factor Surveillance System physical activity questionnaire. Participants who were regular NSAID users also were excluded because the study included an exploratory aim examining change in serum inflammatory markers. The Wash- ington University Institutional Review Board approved the study and written consent was obtained from all participants. Randomization The allocation sequence was determined by random.org prior to participant enrollment. Sequentially numbered envelopes concealed the randomization to either group. The randomization was sealed in an envelope by a blinded staff member. The intervention coach opened the envelope following baseline assessment and informed participants. A blinded staff member completed all follow up data collection. Intervention The SDCC Pilot was a group-based intervention weekly for four weeks followed by eight weeks of once-weekly phone-based follow- up. Outside of group meeting times, which included a group walk, participants were expected to walk on their own, progressing over time to reach their respective study arm goal. In previous versions, FSP has recommended a standard dose of 30 minutes of walking and 10,000 steps per day. This is consistent with the current federal physical activity guidelines for health [7]. Research in colon cancer survivors suggests that 60 minutes of physical activity is needed to prevent recurrence and improve survival [12,13] as well as to manage weight [37], which is independently associated with colon cancer risk [38]. Thus, we added a study arm that delivered a higher dose of physical activity (60 minutes of walking, 13,000 steps per day). The group sessions lasted four weeks and were led by intervention coach. The sessions consisted of individual progress reports, a brief walk of increasing duration, strategy discussion, and individual goal setting for the following week. Between sessions, participants walked on their own, wearing pedometers to PLoS ONE | www.plosone.org 2 July 2012 | Volume 7 | Issue 7 | e39719