A supervised home-based exercise program for breast cancer survivors' functional performance (Home-PAC): a pilot study

doi:10.21203/rs.3.rs-3150410/v1

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A supervised home-based exercise program for breast cancer survivors' functional performance (Home-PAC): a pilot study

https://doi.org/10.21203/rs.3.rs-3150410/v1

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Introduction. Hormonal therapy has adverse effects that hinder breast cancer survivors' functional performance and quality of life. Physical activity (PA) can counteract these adverse effects, and home-based exercise interventions might be a potential solution to foster PA adoption in this population. This study aimed to investigate home-based exercise intervention effects on functional performance, quality of life and PA of breast cancer survivors’ undergoing hormonal therapy. Adherence to the intervention and adverse events were also reported.

Method. This study was a 12-week randomised controlled trial comprising a home-based exercise intervention supported by an exercise booklet including six exercise groups and a weekly online exercise group session. Eighteen women were recruited from Hospital Universitário do Barlavento Algarvio.

Results. Significant time-by-group effects in functional performance (sit-to-stand (p=.033), arm curl (p=.011), and timed up-and-go (.009) tests), quality of life (insomnia (p=.007) and breast symptoms (p=.035)), and PA (vigorous PA (p=.033), walking (p=.005), and total PA (p=.034)), favouring the intervention group were found. Attendance to the supervised component of the program was high (80%).

Conclusion. This home-based exercise intervention was well tolerated and accepted by participants and led to significant improvements in functional performance and PA levels. These findings further support the effectiveness of this type of intervention, which is a more affordable and viable strategy to raise PA levels and enhance functional performance in breast cancer survivors. Exercise professionals may use these programs to promote active lifestyles while reducing barriers to practice.

breast cancer

home-based

functional performance

physical activity

adherence

Breast cancer affects and is a cause of death for many women worldwide[1], [2]. Hormonal therapy is used to treat hormone receptor-positive breast cancer patients, considered an important treatment delivered in the adjuvant setting for 5 to 10 years[3], [4]. This therapy produces many adverse effects that hinder breast cancer survivors’ functional performance (i.e., the person’s ability to carry out daily activities that require physical effort) and quality of life[5]–[7] .

Physical activity (PA) can counteract many physiological and psychological treatment- and therapy-related side effects[8], [9]. However, breast cancer survivors show low compliance with PA guidelines (i.e. 150 min of moderate or 75 min of vigorous aerobic activities per week, strength training 2 to 3 times and flexibility exercises for major muscle groups on activity days)[10]–[12].

Home-based exercise programs can be a feasible strategy to improve breast cancer survivors' PA levels, quality of life, and functional performance, overcoming commonly reported barriers to PA practice, such as the lack of time, motivation, travelling, and financial issues[13], [14]. A systematic review investigating the health outcomes of nine home-based exercise interventions in cancer survivors showed high adherence levels (71–88%) in five of them and multiple physiological benefits[15]. Coughlin et al. (2019) showed that this type of intervention increased PA levels and improved functional performance, aerobic capacity, body composition, and quality of life in this population[13]. One study conducting a supervised home-based exercise program reported significant improvements in breast cancer survivors' quality of life and functional performance[16]. However, the number of existing supervised home-based interventions remained scarce[17], [15], [18].

Hence, this pilot randomised controlled trial investigated the effects of a 12-week structured home-based exercise intervention, comprising one weekly supervised group exercise session, on functional performance (primary outcome), quality of life and PA levels (secondary outcomes) of breast cancer survivors’ undergoing hormonal therapy. Adherence to the intervention and related adverse events were also investigated.

We hypothesise that the intervention group will improve functional performance and quality of life more than the control group. We also expect that the intervention group presents greater PA levels by the intervention's end than the control group.

Study design. The Home-PAC trial is a two-arm pilot randomised controlled trial comprising a 12-week structured and supervised home-based exercise intervention, comprising one weekly group exercise online session, compared to a usual care control group.

This study was conducted in collaboration with Universitario Hospital Center from Algarve (CHUA). It is a subsidiary trial of the PAC-WOMAN (NCT05860621), as it applies and tests its exercise booklet tool, developed to support and guide participants in their unsupervised physical activities at home or other unsupervised contexts.

Ethics approval

was obtained before study implementation from the Ethics Committee of Sports and Physical Education Faculty and from the Investigation Support Unit from CHUA (ref. 216.22). The trial was conducted under the declaration of Helsinki for human studies from the World Medical Association[19].

Participants. Twenty-one women were recruited from a convenience sample from CHUA.

Inclusion criteria: 1) women between stage I-III breast cancer diagnosis stage, aged between 18–75 years old; 2) currently receiving hormonal therapy after completing primary treatments; 3) reporting low to moderate levels of PA on the International Physical Activity Questionnaire (IPAQ); 4) having access to a computer with internet; 5) providing written informed consent; 6) available for online sessions or phone call.

Exclusion criteria: 1) women with medical contraindications to exercise; 2) having physical or psychiatric illnesses or conditions that enabled them to perform the assessments and/or the intervention (e.g. pregnancy or non-controlled heart, metabolic or respiratory diseases); 3) evidence of stage IV cancer, new or recurrent tumours; ) already in an exercise program.

Procedures

Participant selection. Medical professionals selected potential participants and provided a contact list. One researcher (PGFR) contacted potential participants via phone or text message to gauge their interest in the project and invited them for an informational meeting where project details were explained, doubts cleared, and interested participants signed the written informed consent.

Randomisation. After baseline assessments, participants were randomly assigned to either intervention group or usual care control group using GraphPad (https://www.graphpad.com/quickcalcs/randomize1/).

Intervention

Home-based exercise intervention group. Women in this group received an exercise booklet, including different exercises to be performed at home, accompanied by QR codes with instructive videos, how to structure the training sessions, PA guidelines, safety measures, alert signs to attend before and while exercising, and required equipment. Instructions and demonstrations of the booklet exercises and how to use the perceived exercise effort tool (Borg's scale) and assemble their sessions were provided through an online session.

A weekly 50-minute online exercise group session using Zoom software was delivered to provide exercise execution corrections and advice on achieving proper volume and intensity in unsupervised training sessions. Each session included a 10-minute warm-up with mobility and activation exercises, a 30-minute component with aerobic and resistance exercises, and a 10-minute cooldown with breathing and stretching exercises [20]. Participants were encouraged to perform 2 additional unsupervised training sessions per week using the exercise booklet and perform brisk walks at a moderate to vigorous intensity.

Exercise logs. Exercise logs were emailed to all participants to register and self-monitor the frequency, volume, perceived intensity and type of activities performed on unsupervised training and control any exercise-related adverse events. Participants were asked to send their weekly logs for tailored feedback from the exercise professional.

Control group. This group was asked to maintain usual care and current daily routines. After the intervention, participants were offered the exercise booklet and the Home-PAC intervention. During the intervention period, participants received six phone calls or a text message every 2 weeks to maintain their interest in the study. No discussion, encouragement or counselling on PA was provided[21]. A log was filled including the length of the calls, participants' health status, dropout reasons (if applicable), and other relevant information.

Assessments

All assessments were performed at baseline and end-of-intervention (12 weeks), in standardised conditions, at a local sports centre.

Demographics. Age, education level, PA history, and treatment details (breast cancer stage, dates and types of primary treatments, starting date, and type of hormonal therapy received) were collected from participants’ medical records and a general information questionnaire.

Functional performance (primary outcome). Functional performance was assessed by measuring strength (30-s chair stand and arm curl), agility (8-Foot Up and Go), aerobic capacity (6-minute walk), and flexibility (chair sit-and-reach and back scratch) [22]–[24].

Quality of life (secondary outcome). The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and breast cancer module (EORTC QLQ-BR23) were used to assess the cancer-related quality of life[25], [26]. EORT QLQ C-30 is a 30-item questionnaire comprising 8 multi-item functional and symptom subscales, one global health status and quality of life subscale, and 6 single items. Scores range from 0 to 100 for all scales. High scores in global health and functional scales reflect a higher quality of life and functioning, whereas high scores in symptoms reflect elevated levels of problems[25], [27]. The breast cancer module QLQ-BR23 includes 23 questions grouped into 6 functional and symptom subscales. High scores on functional scales show better functioning, and high scores on the symptoms scale and body image represent higher issues[25], [27].

PA (secondary outcome). The IPAQ-SF[28] was used to assess PA levels. The IPAQ-SF is a 9-item questionnaire that measures the weekly time spent on various intensities of physical activity (i.e., light, moderate, and vigorous) and sitting time during the week and weekend days. Total PA scores and discrimination by intensity were derived from the data collected (min/week)[28], [29].

Adherence and adverse events (other outcomes). Adherence was assessed through inspection of exercise logs, which included the duration, frequency, type of activity, rate of perceived exertion, using the Borg CR-10 scale, and self-reported adverse effects felt during exercise[30]–[32]. Adherence to the supervised sessions was assessed through presence calculations and a registry.

Statistical procedures

All statistical analyses were performed using SPSS Statistics (version 26). The significance level of the statistical test was determined at 5%. Descriptive statistics were used to characterise sample features, levels of adherence to the intervention and reported adverse events. Independent Sample T-tests were used to compare both groups at baseline. Factorial Ancovas with repeated measures, adjusting for potential covariates (e.g., primary treatment, length of therapy), were conducted to explore time by group interaction and between and within changes in the study's primary and secondary outcomes (functional performance, quality of life and PA). Kolmogorov-Simonov tests were conducted to test the normality of the outcome variables, and in cases where normality was not satisfied, non-parametric tests (e.g. Kruskal-Wallis) were performed.

Participant characteristics

Twenty-one participants were randomly assigned into intervention (n = 11) or control (n = 10) groups. Across the study period, one participant from the intervention group withdrew due to time management issues, and two participants from the control group dropped out because of personal issues (n = 1) and health issues (n = 1). Complete data from 18 participants were collected and included in the final analysis. The participants' process is presented in Fig. 1, following the recommendation of the Consolidated Standards of Reporting Trials (CONSORT)[33]. Participants' age ranged from 41 to 70 years old. Baseline characteristics are shown in Table 1. There were no differences between intervention and control groups for demographic, functional performance, quality of life, and PA variables.

Table 1

Participant characteristics at baseline.
Demographics	Intervention group (n = 10)	Control group (n = 8)
Age (years)	54.4 ± 9.14	53.0 ± 6.78
Diagnosis stage
I	4	5
II	5	3
III	1	0
Surgery
Lumpectomy	4	7
Partial mastectomy	1	0
Full mastectomy	5	1
Sentinel node removal
Yes	8	7
No	2	1
Chemotherapy
Yes	3	1
No	7	7
Radiotherapy
Yes	6	7
No	4	1
Other therapies (Zoladex; Transtuzmab)
Yes	4	1
No	6	7
Time since diagnosis (years)
≤ 1	1	0
1–2	5	5
2–3	2	0
3–4	1	2
≥ 5	1	1
Hormone therapy
Anastrozol/Letrozol	6	5
Tamoxifen	4	3
Time since Beginning HT (Years)
≤ 1	4	2
1–2	3	3
2–3	1	0
3–4	1	2
≥ 5	1	1

Functional performance (Senior’s Fitness Tests)

Table 2 presents the mean values of all the functional performance tests performed in the two groups at baseline and 12-week measurements. From baseline to post-intervention, there was a significant group-by-time effect in the sit-to-stand test (p < .001), arm curl (p = .002), and timed up and go (.002), favouring the intervention group. No significant group-by-time effect on the sit-and-reach (p = .723), back scratch (p = .809) and 6-minute walk tests (p = .080). Results were similar after adjusting for relevant confounders.

Table 2

ANOVA for repeated measures analysis for functional performance measured through Seniors Fitness Tests.
Variable	Intervention group (n = 10) Mean ± SD
	Baseline	12 weeks	Baseline	12 weeks	Unadjusted	Adjusted
Sit-to-stand (reps)	12.90 ± 4.04	21.30 ± 5.31	13.63 ± 3.62	15.13 ± 2.90	.000*		.033*
Arm Curl (reps)	14.50 ± 3.06	24.40 ± 3.84	15.13 ± 2.48	21.78 ± 4.43	.002*		.011*
Sit-and-Reach (cm)	-1.30 ± 10.23	-1.05 ± 8.92	.38 ± 7.44	1.69 ± 8.68	.723		.493
Back scratch (cm)	-6.40 ± 12.69	-3.30 ± 12.16	-2.63 ± 6.84	− .19 ± 6.86	.809		.289
Timed up & go (sec)	5.21 ± .80	4.42 ± 0.65	4.82 ± 0.46	4.77 ± 0.45	.003*		.009*
6-Min Walk Test (meters)	417.15 ± 146.25	557.35 ± 39.97	477.24 ± 41.80	507.11 ± 80.09	.080		.826
p, significance value of the ANOVA for Repeated Measures analysis *p < .05; Adjusted covariates: Cancer Stage at diagnosis; Existence of mastectomy and sentinel node removal surgery; Adjuvant chemotherapy, radiotherapy, or other therapies (i.e., hormonal therapy (Zoladex, Transtuzmab)

Quality of life

Table 3 presents the mean values for each functional and symptom scale of the two groups between baseline and 12-week measurements. A significant group-by-time effect was found for insomnia (p = .026) and global health status (p = .020), favouring the intervention group. After adjusting for confounders, insomnia remained significant (p = .007), but global health status was no longer significantly different (p = .157). Also, breast symptoms became significant (p = .035), being lower in the intervention group (thus, more favourable in this group). A significant group-by-time effect was found in sexual function (p = .031), favouring the control group after adjusting for confounders. No other significant effects or differences were found in other domains.

Table 3

ANOVA for repeated measures analysis on the Quality of Life measured through the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ C30) and specific breast cancer module (QLQ-BR23).
Variable	Intervention group (n = 10) Mean (SD)		Control group (n = 8) Mean (SD)		Time/Group Interaction (p)
	Baseline	12 weeks	Baseline	12 weeks	Unadjusted	Adjusted
EORTC-QLQ C30 (0-100)
Physical Functioning	82.00 ± 13.72	86.67 ± 10.89	80.83 ± 15.71	85.19 ± 13.44	.785	.161
Role Functioning	80.00 ± 21.94	86.67 ± 13.15	81.25 ± 35.00	85.19 ± 24.85	.500	.947
Cognitive Functioning	73.33 ± 32.58	76.67 ± 11.65	75.00 ± 26.73	83.33 ± 15.43	.610	.808
Emotional Functioning	67.50 ± 23.72	74.17 ± 22.38	75.00 ± 31.81	68.75 ± 28.78	.103	.070
Social Functioning	86.67 ± 15.32	85.00 ± 16.57	81.25 ± 27.37	89.58 ± 19.80	.285	.910
Dyspnea	7.41 ± 14.70	3.70 ± 11.11	8.33 ± 15.43	7.84 ± 14.58	.347	.446
Pain	33.33 ± 29.40	33.33 ± 22.22	22.92 ± 33.26	20.83 ± 35.36	.861	.784
Appetite Loss	13.33 ± 32.20	3.33 ± 10.54	12.50 ± 35.36	16.67 ± 35.64	.128	.197
Fatigue	31.11 ± 26.08	22.22 ± 16.56	25.00 ± 26.39	36.11 ± 30.72	.083	.140
Insomnia	46.67 ± 39.13	13.33 ± 17.21	25.00 ± 23.57	29.17 ± 37.53	.026*	.007*
Constipation	20.00 ± 42.16	3.33 ± 10.54	12.50 ± 24.80	12.50 ± 24.80	.250	.161
Nausea and Vomiting	5.00 ± 11.25	1.67 ± 5.27	4.17 ± 7.72	10.42 ± 23.47	.261	.563
Diarrhoea	3.33 ± 10.54	.00 ± .00	.00 ± .00	.00 ± .00	.420	.523
Financial Difficulties	10.00 ± 16.10	6.67 ± 14.06	25.00 ± 38.83	33.33 ± 43.64	.260	.218
Global Health Status and Quality of Life	65.83 ± 22.72	77.50 ± 11.82	73.81 ± 26.54	60.71 ± 30.70	.020*	.157
QLQ BR-23 (0-100)
Therapy Side Effects	17.46 ± 17.98	13.76 ± 11.03	18.06 ± 16.14	19.05 ± 15.48	.341	.098
Hair Loss	33.33 ± .00	33.33 ± 0.00	33.33 ± 0.00	33.33 ± 33.33	1.0	N/R
Body Image	67.50 ± 34.35	83.33 ± 25.46	73.96 ± 28.33	77.08 ± 24.30	.124	.350
Future Perspective	55.56 ± 33.33	51.85 ± 44.44	41.67 ± 34.50	45.83 ± 35.36	.705	.525
Sexual Function	66.05 ± 22.81	66.67 ± 25.00	59.03 ± 24.30	70.83 ± 23.15	.229	.031*
Sexual Enjoyment	41.67 ± 31.91	50.00 ± 19.25	27.78 ± 25.09	33.33 ± 21.08	.852	N/R
Arm Symptoms	16.67 ± 13.09	23.33 ± 14.30	20.83 ± 18.25	19.44 ± 18.54	.259	.719
Breast Symptoms	22.50 ± 15.74	10.00 ± 11.65	25.00 ± 19.42	21.88 ± 16.02	.174	.035*
Abbreviations: p, significance value of the ANOVA for repeated measures analysis *p < .05; Adjusted covariates: Cancer Stage at diagnosis; Existence of mastectomy and sentinel node removal surgery; Adjuvant chemotherapy, radiotherapy, or other therapies (i.e., hormonal therapy (Zoladex, Transtuzmab) N/R, not reportable

Physical activity levels

Results from the two groups at baseline and 12-week assessment points can be found in Table 4. A significant group-by-time effect was found in vigorous PA (p = .010), walking (p = .009), and total PA (.003), favouring the intervention group. Results remained similar after adjusting for confounders.

Table 4

ANOVA for repeated measures analysis for the Physical Activity Levels measured through IPAQ-SF.
Variable	Intervention group (n = 10) Mean (SD)		Control group (n = 8) Mean (SD)		Time/Group Interaction (p)
	Baseline	12 weeks	Baseline	12 weeks	Unadjusted	Adjusted
Physical Activity (min/week)
VPA	.00 ± .00	112.50 ± 88.67	33.75 ± 49.26	32.50 ± 55.22	.010*	.026*
MPA	138.00 ± 89.67	321.00 ± 234.54	81.88 ± 63.02	107.50 ± 129.15	.159	.637
Walking	72.00 ± 80.25	170.50 ± 86.30	106.88 ± 79.55	81.88 ± 66.87	.009*	.002*
Total PA	210.00 ± 110.45	604.00 ± 241.15	222.50 ± 154.64	221.88 ± 147.79	.003*	.027*
Sitting time (min/day)
Week	306.00 ± 192.25	279.00 ± 213.57	330.00 ± 202.20	258.75 ± 150.38	.317	.250
Weekend	330.00 ± 170.29	267.00 ± 75.43	251.25 ± 161.11	232.50 ± 179.82	.478	.310
Abbreviations: PA, physical activity; IPAQ-SF, International Physical Activity Questionnaire Short Form; MPA, moderate-intensity physical activity; VPA, vigorous-intensity physical activity; METs, metabolic equivalent of task; p, significance value from ANOVA for repeated measures analysis *p < .05

Adherence to the program

Participants from the intervention group participated in an average of 9.6 ± 2.0 out of 12 online sessions (ranging from 6 to 12), corresponding to an average 80% adherence rate. An average of 7.7 ± 4.1 out of 12 weekly logs were retrieved from the participants (64.8%).

In the exercise logs retrieved from the intervention group, participants showed that, besides the weekly online session, they performed an average of 2.2 ± .6 days of aerobic exercise (ranging from 0 and 7 days) for an average of 82.4 ± + 21.9 minutes (range between 0 and 210 minutes) and 1.7 ± .4 resistance training unsupervised sessions (range 0 to 6 sessions) per week.

Adverse events

During the intervention, participants from the intervention group reported pain in the shoulder (n = 4), knee discomfort during sit-to-stand exercises or walking (n = 5), dizziness during walking (n = 4), arm discomfort during unsupervised training sessions (n = 1), joint and muscle pain (n = 2), and back pain (n = 2). However, some adverse effects were felt due to a pre-existing condition or old injury (n = 4). In many cases, the adverse effects were reduced or eliminated across the intervention period (n = 8), particularly in dizziness during walking, knee discomfort at sit-to-stand exercises, and joint and muscle pain. None of the adverse effects was reported as being aggravated by the exercise performance, and with the correct adaptations, the participants continued the program, and none of them dropped out.

This pilot randomised controlled trial aimed to investigate the effects of a 12-week structured home-based exercise intervention, including a supervised group session, on functional performance, quality of life, and PA levels of breast cancer survivors undergoing hormonal therapy.

This study showed the intervention's positive effects on the breast cancer survivors’ functional performance, especially in the sit-to-stand, arm-curls, and timed up-and-go tests. Although not significant, results also suggest improvements in sit-and-reach, back scratch, and 6-minute walk tests, which might be clinically relevant since primary cancer treatments and hormonal therapy induce muscle loss and dysfunction and shoulder dysfunctions limiting movement and hence the performance of daily activities among breast cancer survivors[34], [6]. Furthermore, improvements in the 6-minute walk test can indicate better overall health, and improved aerobic capacity, related to a risk reduction of premature mortality and development of cardiovascular diseases[35], [36]. Batalik et al.[15] systematic review also indicated improvements in strength as a benefit deriving from home-based exercise interventions. A study of Dong et al.[16], involving a structured and supervised home-based intervention, reported significant changes in sit-to-stand and arm lifting tests.

Regarding the cancer-related quality of life domains, the participants from the intervention group reported higher global health status and quality of life, lower levels of insomnia, therapy side effects, and breast symptoms compared to the control group. Zhang et al.[37] systematic review also showed the positive effects of exercise on breast cancer survivors’ quality of life. The significant effects reported on insomnia scores may indicate better sleep quality resulting from the intervention. This finding is in line with other studies that analysed this variable and is clinically relevant since insomnia has been associated with impairment in the performance of daily tasks, more symptoms of pain, and poorer mental and physical health in prior studies[38], [39].

Significant increases were found in vigorous-intensity PA, walking time, and total PA in the intervention group. The findings in this study support previous systematic reviews conducted by Coughlin et al.[40] and Batalik et al.[15], also reports home-based exercise interventions' contribution to increasing cancer survivors’ PA levels.

Regarding sitting time, although it was not significant, a positive effect was found that might have clinical significance since higher amounts of sedentary behaviour are associated with worse physiological and functional outcomes and higher risk of all-cause mortality, even after controlling for PA levels in breast cancer survivors[41].

The non-significant differences between groups might be related to the small sample size and to the fact that the control group also improved in several aspects, probably influenced by the participation in the study and baseline assessments, leading to some lifestyle changes, a fact that it is not uncommon in experimental studies[42].

Adherence to the online group sessions was high (80%), which aligns with other home-based interventions’ results. It solidifies the idea that home-based exercise interventions appeal to this population for their schedule flexibility and affordability[14].

To our knowledge, few articles have investigated home-based exercise interventions that included a supervised component. According to Depenbusch et al.[43] focus group study, breast cancer survivors consider professional support and supervision during exercise essential to overcome their perceived barriers and insecurities. And, effectively, though adverse events were reported by participants, none of them was aggravated by exercise practice. Some symptoms even reduced or disappeared across the intervention period (i.e., dizziness and knee discomfort, and joint and muscle pain), and none of the participants dropped out of the program. This finding suggests that exercise performed at home might be safe and effective in reducing some hormone therapy-related symptoms when monitored and supervised by an exercise professional.

Besides the supervised session, the booklet delivered to the participants was specifically built for breast cancer survivors, and tailored feedback was given after each session to participants who submitted their exercise logs, providing them with solutions to any identified barriers and encouraging them to maintain or increase their activity levels. As a result, participants remained more active behaviour throughout the intervention. In fact, providing feedback and incentive to breast cancer survivors has been shown to facilitate active behaviour adoption and maintenance[44] potentially, emphasising the relevance of this type of exercise intervention (home-based, structured and supervised).

Strength and Limitations

This study is one of the few that performed a home-based exercise intervention with a direct supervision component and using the Denton et al.[45] classification domains, contributing to enlarging the accuracy and consistency of the literature in the classification and description of this type of intervention. Future studies may follow the same concept, facilitating intervention description and effectiveness comparability among interventions. Potentially, this might help to understand whether certain types of home-based exercise programs are, in some measure, suitable for specific cancer populations and treatment phases. This home-based exercise program comprised aerobic, resistance and mobility components, therefore in line with the latest exercise guidelines for cancer survivors[11]. In contrast, this program was not entirely supervised, having a self-practice component, differently followed by the participants, leading to discrepancies in the activity levels adopted by each participant, which may cause a certain (“real world”) degree of variability in the results. The lack of human and time resources was one of the main reasons for the choice of having only one group session per week, which could have limited the magnitude of improvements. Still, cost-effective scalable solutions are currently needed, and this design appears feasible.

Results suggest a positive effect of the intervention on the breast cancer survivors’ functional performance, PA levels, and some aspects of quality of life. Future studies would do well to replicate this pilot study with larger samples to draw more solid conclusions. PA levels were assessed through self-reported measures, which rely on participants’ memory and interpretation, leading to overestimation or underestimation compared to objective measurement methods (i.e., accelerometers)[46], [47]. Due to the lack of financial resources and the unavailability of objective instruments, questionnaires were the most convenient and affordable way to collect data on the participant’s PA. Future studies might use objective PA measurement tools (e.g., accelerometers, pedometers or activity monitors) to estimate more accurately the levels of PA of the participants, allowing more solid conclusions on the effectiveness of the home-based exercise programs on this outcome[48]. During the intervention period, the control group was followed through phone calls or messages, to motivate and control their PA since some participants mentioned already performing some activity (i.e., walking), thus constituting a potential cofounder. However, adverse events were not monitored in the control group, preventing exploring these factors’ influence on the changes in the main outcomes.

Practical implications

This study showed that this home-based exercise program is feasible and inexpensive to apply since no special equipment is needed and might effectively improve PA levels and functional performance in breast cancer survivors. Women participating in the intervention used every object available at their home as viable tools to exercise (water bottles, towels, chairs, among others), which worked effectively and suggest that this kind of intervention can be inexpensive to apply. Also, it allows the professional to widen its reach to more patients since it does not require travelling or special facilities or equipment. In this study, participants were spread across the region. Without this training system, many would not have had the opportunity to exercise with the supervision and counselling of a certified exercise professional. Applying these types of programs benefits the patients by fostering their confidence to exercise safety under professional supervision and tailored feedback.

This study revealed a positive effect of a structured home-based exercise program with a supervised component on participants’ functional performance and PA levels, with high levels of adherence. Results suggest that home-based exercise interventions might be a feasible and inexpensive strategy to reduce some breast cancer survivors’ perceived barriers to PA and improve their active behaviour by reaching subjects who do not have supervised exercise opportunities nearby home or lack financial resources for it. Professionals may adopt this type of program to promote PA among breast cancer survivors allowing them to benefit from its multiple positive health effects. Future studies are needed to continue exploring different types of home-based exercise programs with supervised components, using larger samples, exploring different ratios of supervised/unsupervised settings, and applying for these programs in other stages (e.g., pre-habilitation and during neoadjuvant and adjuvant therapies).

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Funding

This study is a subsidiary study of the PAC-WOMAN trial, funded by Fundação para a Ciência e Tecnologia (Grant number: PTDC/SAU-DES/2865/2020). The Municipal Sports Department of Portimão provided space and materials for the measurements and insurance for the participants.

Authors’ contributions

PGFR, EVC, and PBJ conceptualised the manuscript. PGFR wrote the manuscript. EVC and PBJ assisted in the drafting of the manuscript. PGFR implemented the trial, performed participants’ assessments, and conducted data analysis. IN and BR built the exercise booklet. GV and AB participated in patient recruitment. EVC and PBJ revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors thank the Algarve Oncology Association for assisting the project by calling the control group participants. We also thank to all the PAC-WOMAN research team, involved in the production of the exercise booklet.

Availability of data and materials

Anonymised trial data will be available from the corresponding author upon reasonable request for non-commercial research purposes.

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A supervised home-based exercise program for breast cancer survivors' functional performance (Home-PAC): a pilot study

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