Physical Activity Level Effect on Cognitive Level And Quality Of Life in Patients with Breast Cancer: A Case Control Study Investigation Of The Relationship Between Physical Activity Level And Quality Of Life In Patients With Breast Cancer

doi:10.21203/rs.3.rs-4891065/v1

Purpose

To determine the level of physical activity, quality of life and cognitive level in patients undergoing breast cancer treatment and to compare the results with a healthy population of similar age group.

Methods

Our case-control study was conducted with chemotherapy patients (CG) diagnosed with breast cancer (breast Ca) treated in the Department of Oncology and healthy control group (HCG) with similar demographic characteristics. he participants' physical activity level was assessed using the International Physical Activity Questionnaire (IPAQ), their quality of life using the EORTC-QLQC30 Quality of Life Scale, and their cognitive level using the Montreal Cognitive Assessment Scale. The Mann-Whitney U test was used to determine differences between groups. A level of p < 0.05 was considered statistically significant.

Results

In our study in which breast Ca (n = 38, age = 52.96 ± 11.37 years, height = 162.22 ± 6.28cm, weight = 71.07 ± 12.91kg, chemotherapy cycle = 4.33 ± 6.86 cycles) and healthy control group (n = 30, age = 51. 1 ± 12.39 years, height = 161.63 ± 6.33cm, weight = 70.23 ± 12.761kg), the physical activity level was significantly lower in the breast cancer group than in the control group (p < 0.0001, z=-4.101). Similarly, the cognitive level (p < 0.0001, z=-3.258) subscores were significantly lower in the breast ca group compared to the control group. While the overall quality of life score did not differ from healthy controls (p < 0.0001, z=-4.101), the physical, social, emotional, fatigue and vomiting subscores were significantly lower than healthy controls.

Conclusion

The level of physical activity was found to be lower in patients after breast cancer compared to their healthy counterparts. In addition, levels of social support and role functioning, which indicate quality of life, and disease-specific symptoms such as pain, nausea, vomiting, and constipation were different from those in the healthy control group. Therefore, these variables should be taken into account in the exercise programme given to breast cancer patients.

Clinical Trial Registration number: NCT05275517 Submission Date: 05/09/2023

Breast Cancer

Chemotherapy

Physical Activity

Cognitive Level

Quality of Life

Breast cancer is one of the most common cancers and a growing health concern as the leading cause of cancer death [1]. GLOBOCAN 2020 estimates that breast cancer has overtaken lung cancer as the leading cause of cancer death in women. Sung et al. reported that breast cancer accounted for 2.2 million new cases, nearly 12% of total cancer incidence [2]. Today, breast cancer survival rates are increasing due to advances in treatment. However, with longer survival comes an increased risk of experiencing symptoms, including various physical and/or psychosocial side effects after breast cancer treatment [3–5]. Dealing with these health problems can have a negative impact on physical and mental well-being, leading to reduced health-related quality of life (HRQoL) and reduced work capacity [6]. It is therefore important to plan interventions to improve HRQoL in breast cancer survivors and to identify modifiable factors associated with their well-being.

Another factor affecting quality of life in patients receiving breast cancer treatment is the impact on cognitive function. Between 30% and 35% of women with breast cancer report poorer cognitive status [7]. This is evidence that cancer treatment leads to lower cognitive levels [8]. The cognitive level of cancer patients is also influenced by physical activity. This effect is greater in middle age and older. For this reason, there is still a need for studies to investigate the factors that influence reduced cognitive level after cancer [9]. There is also a paucity of relationship studies in the literature on breast cancer patients. In the study by Page et al. investigating the relationship between physical activity and cognitive level in women diagnosed with breast cancer, the aim was to design our study as a face-to-face study and to obtain more objective results due to the fact that the study was conducted on IPad and not compared with the healthy control group and the generalisability of the sample was low [10].

The aim of this case-control study was to determine the level of physical activity, quality of life and cognitive level in patients treated for breast cancer and to compare these results with a population of similar age.

Our case-control study was conducted between 15 January 2022 and 15 June 2022 with patients diagnosed with breast cancer and undergoing chemotherapy at the Department of Oncology, Aydın Adnan Menderes University Faculty of Medicine Research and Application Hospital and their healthy peers who were not diagnosed with cancer. The study was approved by the Non-Interventional Ethics Committee of Aydın Adnan Menderes University Faculty of Health Sciences (E-15189967-050.04.04-118775).

In the G-Power power analysis performed according to the moderate physical activity score data from the study by Benton et al. investigating quality of life and physical activity levels in patients with breast cancer, it was determined that 27 individuals in each group and 54 individuals in total should be included to have 80% power with 95% confidence, assuming an effect size of f:0.78 [11].

Patients

In our study, patients diagnosed with breast cancer formed the study group (WG) and healthy peers formed the control group (CG). Patients who were diagnosed with cancer at least 3 months prior to the study and underwent chemotherapy treatment at Aydın Adnan Menderes University Faculty of Medicine Research and Application Hospital Oncology Department, had a Mini-Mental Test score of at least 24, had a life expectancy of more than 6 months, were aware of the diagnosis, were over 18 years old, were healthy peers, and had a score of at least 24 on the Mini-Mental Test, Healthy volunteers over the age of 18 who had not previously been diagnosed with or treated for cancer and who did not have a disease that would affect their cognitive function were included in the study. Patients with brain metastases, cognitive and psychiatric problems, patients with haematological cancers receiving palliative care, and volunteers with systemic diseases, chronic diseases, and problems that would prevent physical activity were not included in the study.

Participants who met the inclusion criteria for the research and control groups were asked to complete the questionnaires described below under the observation of the researcher. The questionnaire was administered in an assessment room where the participant could answer the questions comfortably.

Data collection and definitions

Demographic Information Form

The socio-demographic characteristics of the participants, such as age, height, weight, educational status, marital status, diagnosis, were recorded using the form developed by the researchers based on the literature.

Level of physical activity

The IPAQ long form was used to measure the amount of physical activity during the past 7 days. The 27-question questionnaire assesses in detail the amount of walking done in the past week and the amount of moderate to vigorous physical activity during work, transport, housework, gardening and leisure time activities.

Its validity and reliability in Turkey were assessed by Öztürk in 2005 [12]. Patients' level of physical activity is determined by at least 10 minutes of physical activity in the last 7 days.

Vigorous physical activity (VPA) is calculated by asking about activities such as weight lifting, aerobics, digging, football, fast cycling in minutes. Moderate physical activity (MVPA) is calculated in minutes for activities such as carrying light loads, folk games, dancing, table tennis or bowling. Walking and sitting for 1 day are also calculated in minutes.

The physical activity score is calculated by multiplying the participant's vigorous and moderate physical activity and walking times in the previous week by the number of minutes, days and MET-minute value appropriate for the physical activity performed (MET-minute/week) using the formulae below.

Standard MET values exist for these physical activities.

Walking score (MET-min/hf) = 3.3
Moderate activity score (MET-min/hf) = 4.0
Heavy activity score (MET -min/hf) = 8.0

For example, the walking MET-min/week score for a person who walks 20 minutes 5 days a week is calculated as 3.3x20x5 = 330 MET-min/week. The total walking score is obtained by summing the walking scores in each domain. This provides continuous data. The total physical activity score (MET-min/hf) is obtained by summing the scores for walking, moderate activity and vigorous activity.

There are three levels of physical activity, namely 'inactive', 'minimally active' and 'very active (health-enhancing physical activity)'. The criteria for these levels are calculated by calculating the continuous scores mentioned above [12].

Quality of life

The EORTC-QLQ-C30 Quality of Life Scale, developed by the European Organisation for Research and Treatment of Cancer (EORTC), whose content validity and reliability study was conducted by Beşer and Öz in cancer patients (Cronbach's alpha coefficient, r = 0.9014), was used to assess their quality of life [13]. The EORTC-QLQ-C30 Quality of Life Scale consists of 30 questions with three subscales: general well-being, functional difficulties and symptom control. The first 28 of the 30 items in the scale are four-point Likert scales, and the items are None: 1, Somewhat: 2, Somewhat: 3, or Very much: 4 points.

Question 29 of the scale asks the patient to rate their health on a scale of 1 to 7 (1 being very poor and 7 being excellent) and question 30 asks the patient to rate their general quality of life. Questions 29 and 30 are the questions that make up the general wellbeing domain. High scores in this section indicate a high quality of life, while low scores indicate a lower quality of life. In the functional domain and symptoms sections, low scores indicate high quality of life and high scores indicate low quality of life [13].

Cognitive level

The Montreal Cognitive Assessment Scale (MCAS), validated by Selekler et al, is used to assess cognitive function. This test, which takes an average of 10 minutes to complete, assesses various cognitive functions including attention and concentration, executive function, language, memory, visual structuring, abstract reasoning, calculation and orientation. The maximum score that can be achieved on the test is 30. Individuals scoring 21 and above are considered to have normal cognitive status [14].

Executive function is assessed with the sequential number and letter combination test (1 point) and verbal fluency (1 point). 31 The clock drawing test (3 points) and the three-dimensional cube copying test (1 point) assessed visual structuring skills, and the tests of naming animal pictures and repeating the same sentence in the same way assessed language skills. To assess memory functions, individuals were asked to read and repeat five words and the number of words that could be recalled after a delay of 5 minutes (5 points). To assess attention and concentration functions, participants were asked to count numbers forward and backward in sequence (1 point each), to subtract consecutively, and to identify the desired letter among different letters read (1 point). To assess abstract thinking skills, questions were asked about finding similarities between words (2 points) and time and place orientation (6 points) to assess orientation [14].

Data analysis

Data analysis was performed using SPSS version 24.0 (IBM). Descriptive statistics were used to analyse the physical activity, quality of life and cognitive characteristics of the participants. Data from healthy and cancer patients were compared. The t-test was used when the data were normally distributed, and the Mann-Whitney u test was used when the data were not normally distributed.

Within the framework of our study, 82 patients were reached at Aydın Adnan Menderes University. 11 patients did not want to participate in our study. 3 patients were not included in our study because they did not meet the inclusion criteria. As a result, our study was completed by including 34 patients in the study group and 34 individuals in the control group.

The demographic characteristics of the individuals who participated in our study are shown in Table 1. In the study group, 68% (n=26) of the patients had a history of cancer-related surgery. In addition, 26% (n=10) of the patients received radiotherapy in addition to chemotherapy.

Table 1. Baseline information of the participants

	Control			Working group
	A.O. ± S.S	Med (IQR)	min - max	A.O. ± S.S	Med (IQR)	min - max	p
Age (years)	51.1 ± 12.39	48.5 (43.75 - 59.25)	28 - 78	54.42 ± 10.43	54.5 (46.75 - 62)	36 - 74	0.234 (t=-1.2)
Height (cm)	161.63 ± 6.33	161 (157 - 165.75)	145 - 175	162.7 ± 6.29	164 (158.5 - 167)	150 - 174	0.493 (t=-0.69)
Weight (kg)	70.23 ± 12.76	68 (61.25 - 78.25)	54 - 117	71.74 ± 13.16	69.5 (62.5 - 80.5)	49 - 106	0.557 (z=-0.587)
Minimental test	9.73 ± 0.45	10 (9 - 10)	9 - 10	9.5 ± 0.86	10 (9 - 10)	6 - 10	0.368 (z=-0.901)
Chemotherapy_cure	-	-	-	8.27 ± 7.58	6 (3.5 - 13)	0 - 36	-
Radiotherapy_cure	-	-	-	1.87 ± 6.67	0 (0 - 0)	0 - 33	-

*p<0.05 statistically significant difference; A.O: Arithmetic mean; S.S: Standard deviation; Med (IQR): Median (25th-75th percentiles); min - max: Minimum - maximum values; t: Independent samples t test; z: Mann Whitney U test

Physical Activity

IPAQ_severe, IPAQ_moderate and IPAQ total scores were found to be higher in the control group than in the study group. Although there was no statistical difference between the two groups, the walking score was relatively higher in the control group (Table 2).

Table 2. Between group comparisons of physical activity levels

	Control			Study
	A.O. ± S.S	Med (IQR)	min - max	A.O. ± S.S	Med (IQR)	min - max	p
IPAQ_severe	3541.33 ± 11206.83	0 (0 - 1480)	0 - 50400	221.05 ± 1116.51	0 (0 - 0)	0 - 6720	0.003* (z=-2.956)
IPAQ_medium	3053.33 ± 3932.65	1800 (830 - 4320)	0 - 20160	628.95 ± 1223.44	90 (0 - 630)	0 - 5320	0.0001* (z=-4.726)
IPAQ_progress	804.65 ± 1443.47	429 (37.13 - 792)	0 - 6930	679.97 ± 782.54	330 (37.13 - 1386)	0 - 3234	0.857 (z=-0.18)
IPAQ Total	7399.32 ± 14499.56	3010 (1599.75 - 6058.5)	480 - 70956	1529.97 ± 1948.88	814.5 (129 - 1836)	0 - 8106	0.0001* (z=-4.101)

*p<0.05 statistically significant difference; A.O: Arithmetic mean; S.S: Standard deviation; Med (IQR): Median (25th-75th percentiles); min - max: Minimum - maximum values; t: Independent samples t test; z: Mann Whitney U test

Quality of life

Physical, social, fatigue, nausea and vomiting, loss of appetite, diarrhoea and financial impact scores were significantly lower in the study group than in the control group (Table 3).

Table 3. Between-group differences in quality of life subscales and total score

	Control			Study
	A.O. ± S.S	Med (IQR)	min - max	A.O. ± S.S	Med (IQR)	min - max	p
Physical	20.22 ± 15.81	19.99 (6.66 - 28.35)	0 - 66.66	42.45 ± 27.79	46.66 (13.32 - 61.67)	0 - 100	*0.002 (z=-3.173)**
Role	8.89 ± 22.63	0 (0 - 0)	0 - 100	19.74 ± 30.72	0 (0 - 33.35)	0 - 100	0.075 (z=-1.782)
Emotional	25.55 ± 30.94	12.49 (0 - 43.76)	0 - 100	34.86 ± 31.05	25 (8.33 - 60.41)	0 - 100	0.091 (z=-1.691)
Cognitive	17.22 ± 18.3	16.65 (0 - 33.3)	0 - 66.7	26.75 ± 33.23	16.65 (0 - 50)	0 - 100	0.543 (z=-0.609)
Social	12.78 ± 26.87	0 (0 - 8.33)	0 - 100	32.02 ± 36.43	16.65 (0 - 54.18)	0 - 100	*0.008 (z=-2.632)**
Fatigue	33.69 ± 27.61	27.75 (11.1 - 44.43)	0 - 100	52.04 ± 33.89	50 (22.2 - 77.78)	0 - 100	*0.027 (z=-2.211)**
Nausea_and_vomiting	6.11 ± 15.47	0 (0 - 0)	0 - 66.7	20.61 ± 32.98	0 (0 - 33.31)	0 - 100	*0.036 (z=-2.094)**
Pain	25.55 ± 29.92	16.65 (0 - 33.3)	0 - 100	25.88 ± 32.58	16.65 (0 - 50)	0 - 100	0.856 (z=-0.181)
Dyspnea	6.66 ± 13.55	0 (0 - 0)	0 - 33.3	12.28 ± 23.79	0 (0 - 33.3)	0 - 100	0.452 (z=-0.752)
Sleep_disturbance	22.21 ± 34.27	0 (0 - 33.3)	0 - 100	37.71 ± 43.27	33.3 (0 - 100)	0 - 100	0.166 (z=-1.384)
Appetite_Loss	14.44 ± 27.24	0 (0 - 33.3)	0 - 100	37.72 ± 44.64	0 (0 - 100)	0 - 100	*0.03 (z=-2.172)**
Constipation	16.66 ± 25.89	0 (0 - 33.3)	0 - 100	14.03 ± 27.54	0 (0 - 33.3)	0 - 100	0.438 (z=-0.775)
Diarrhea	5.55 ± 19.73	0 (0 - 0)	0 - 100	22.8 ± 37.25	0 (0 - 33.3)	0 - 100	*0.018 (z=-2.356)**
Financial_impact	3.33 ± 13.42	0 (0 - 0)	0 - 66.7	42.11 ± 39.28	33.3 (0 - 66.7)	0 - 100	*0.0001 (z=-4.681)**
Global_quality_of_life	62.5 ± 26.33	66.7 (50 - 83.3)	0 - 100	61.4 ± 24.31	66.7 (50 - 83.3)	0 - 100	0.859 (t=0.179)

*p<0.05 statistically significant difference; A.O: Arithmetic mean; S.S: Standard deviation; Med (IQR): Median (25th-75th percentiles); min - max: Minimum - maximum values; t: Independent samples t test; z: Mann Whitney U test

Cognitive level Between-group comparisons

The values for VisualSpatial/Administrative Functions, Montreal_Time, Montreal_Naming, Montreal_Attention and Cognitive Level total scores were statistically higher in favour of the control group (Table 4).

Table 4. Between-group differences in cognitive level subscores and total score

	Control Group			Working Group
	A.O. ± S.S	Med (IQR)	min - max	A.O. ± S.S	Med (IQR)	min - max	p
VisualSpatial/ Executive Functions	1.87 ± 0.57	2 (2 - 2)	0 - 3	1.03 ± 0.72	1 (0.75 - 2)	0 - 2	*0.0001 (z=-4.815)**
Montreal_Hour	2.83 ± 0.59	3 (3 - 3)	0 - 3	1.71 ± 1.29	2 (0 - 3)	0 - 3	*0.0001 (z=-4.071)**
Montreal_Naming	2.77 ± 0.43	3 (2.75 - 3)	2 - 3	2.45 ± 0.55	2 (2 - 3)	1 - 3	*0.013 (z=-2.473)**
Montreal_Caution	5.4 ± 0.86	6 (5 - 6)	3 - 6	4.29 ± 1.74	5 (3 - 6)	1 - 6	*0.004 (z=-2.843)**
Montreal_Lisan	2 ± 1.02	2 (1 - 3)	0 - 3	2.08 ± 1.02	2 (1 - 3)	0 - 3	0.709 (z=-0.374)
Montreal_Abstract thinking	1.77 ± 0.57	2 (2 - 2)	0 - 2	1.68 ± 0.57	2 (1 - 2)	0 - 2	0.393 (z=-0.855)
Montreal_Delayed	2.6 ± 1.65	3 (1 - 4)	0 - 5	2.05 ± 1.74	2 (0 - 4)	0 - 5	0.196 (z=-1.294)
Montreal_Direction	5.9 ± 0.31	6 (6 - 6)	5 - 6	5.84 ± 0.44	6 (6 - 6)	4 - 6	0.666 (z=-0.431)
Total points	24.97 ± 3.39	26 (23 - 27.25)	15 - 30	20.95 ± 5.3	21.5 (16.75 - 25.25)	10 - 29	*0.001 (z=-3.258)**

*p<0.05 statistically significant difference; A.O: Arithmetic mean; S.S: Standard deviation; Med (IQR): Median (25th-75th percentiles); min - max: Minimum - maximum values; t: Independent samples t test; z: Mann Whitney U test

In our case-control study designed to assess physical activity, quality of life and cognitive levels in breast cancer patients and compare them with healthy controls, we found that the physical activity scores of our study group with breast cancer were lower than healthy controls for both vigorous and moderate activity. Similarly, when analysing the quality of life subscales, we found that the physical, social, fatigue and sleep disturbance subscales were significantly lower in the breast cancer study group compared to healthy peers. The spatial function, time, naming and attention subscales were also found to be lower in breast cancer patients than in healthy control.

Our study assessed physical activity levels, quality of life, and cognitive function in patients treated for breast cancer and compared the results with healthy controls. The results of our study showed that the physical activity levels, cognitive functions and quality of life of patients after breast cancer treatment were significantly lower than those of the healthy control group. These findings highlight the importance of the recovery process after cancer treatment and the need to support this process in several dimensions. This finding highlights the negative effects of cancer treatment on physical activity. In line with our study, it has been reported in the literature that patients undergoing cancer treatment experience a significant decrease in physical activity levels during and after the treatment process [15, 16]. Again, Brown et al (2012) found that the physical activity levels of breast cancer patients decreased by two hours per week from pre-diagnosis to post-diagnosis [17]. Increased symptoms such as fatigue, pain and general weakness due to chemotherapy or radiotherapy during and after cancer treatment [18] or surgery [19, 20] may reduce patients' physical activity levels.

It was found that the cognitive levels of breast cancer patients were significantly lower than the control group (p < 0.0001). Patients undergoing breast cancer treatment were shown to have difficulties in cognitive areas such as attention, memory, executive function and processing speed. This finding suggests that cancer treatment may affect cognitive function as well as physical health [21]. Wefel Jeffrey et al (2010) found cognitive decline in breast cancer patients at a rate of 60% in the acute stage and 29% in the later stages of treatment [22]. This decline in cognitive function has been widely reported in the literature as a side effect of chemotherapy, known as "chemotherapy brain" [23]. Recent studies have shown that the use of aromatase inhibitors and tamoxifen affects cognition [24, 25].

Higher levels of physical activity and fitness have been associated with better cognitive characteristics in the elderly and chronically ill [26]. Considering that low and moderate intensity physical activity has beneficial effects on cognitive levels in children and the elderly in light of this evidence, it has been shown that physical activity levels are associated with chemotherapy-induced cognitive impairment in breast cancer patients, confirming the hypothesis of our study [27, 28]. Similar to our study, Bender et al (2021) show that higher levels of physical activity and cardiorespiratory fitness are associated with better cognitive function in breast cancer patients [29]. Considering that only the cognitive levels of older people or only breast cancer patients have been investigated in the literature, our study stands out because it is a comparison study with healthy peers. This makes our study unique. In this context, the importance of cognitive rehabilitation programs after cancer treatment emerges. These programs can help patients regain their cognitive functions and become more independent in their activities of daily living.

The EORTC-QLQ-C30 is one of the most widely used scales for measuring and assessing quality of life in cancer patients. In our study, although the overall quality of life score of patients treated for breast cancer did not differ from their healthy counterparts (p < 0.0001), they were found to be significantly lower in the physical, social, emotional, fatigue and vomiting subscales.

Canário et al. (2016) investigated physical activity and quality of life in 215 breast cancer patients aged 40–60 years and reported that physically active individuals had higher quality of life scores [30]. Aydin et al. also reported that aerobic exercise influenced quality of life in the study group using the EORTC QLQ-C30 scale (physical p = 0.001, role p = 0.039, emotional p = 0.031, social functioning p = 0.010) and symptoms (fatigue p = 0.001, pain p = 0.001, sleep disturbance p = 0. 038 and financial impact p = 0.015).(Functional scales (physical p = 0.001, role p = 0.039, emotional p = 0.031, social functionality p = 0.010) and symptoms (fatigue p = 0.001, pain p = 0.001, sleep disturbance p = 0.038 and financial impact p = 0.015) [31].

These decreases observed in different sub-dimensions of quality of life show how much breast cancer treatment can affect individuals' daily life and general health status. These findings are consistent with the negative impact of cancer treatment on quality of life reported by Aaronson et al (2014) [3]. Fatigue, emotional distress, social isolation and physical symptoms experienced by breast cancer patients are the main factors that negatively affect quality of life [32].

Limitations:

This study is not without its limitations. The relatively small sample size may limit the generalisability of the findings. In addition, the cross-sectional design precludes any conclusions about causality. Longitudinal studies are needed to investigate the long-term effects of breast cancer treatment on physical activity, quality of life, and cognitive function.

The results of this study show that patients undergoing breast cancer treatment have lower levels of physical activity, cognitive function and quality of life than their healthy peers. These findings highlight the importance of comprehensive and individualised interventions to support the physical and psychosocial well-being of breast cancer patients. Exercise programmes, cognitive rehabilitation, and supportive therapies to improve quality of life play a critical role in the recovery process of breast cancer patients.

Future studies should investigate the effects of physical activity and cognitive rehabilitation programmes in breast cancer patients and evaluate the long-term effects of these programmes. The effectiveness of psychosocial interventions to improve patients' quality of life should also be investigated. Such studies will contribute to the development of more effective strategies to improve patients' quality of life and overall health in the post-cancer period.

Conflict of Interest

There are no known conflicts of interest associated with this publication.

Ethics Approval Statement

This case controlled study was conducted following the Declaration of Helsinki. Approval was obtained from the Non-Interventional Ethics Committee of Aydın Adnan Menderes University Faculty of Health Sciences (Date.05.01.2022/No.E-15189967-050.04.04-118775) and written informed consent was obtained from all patients in the trial.

Clinical Trial Registration

The study was registered at Clinical Trials (NCT05275517).

Funding Details

The authors declare that this study received no financial support.

Data Availability Statement

Data are available on request from the authors.

Author Contributions

A.K..: conceptualization and design, acquisition of data, analysis and interpretation of data, and writing of the original draft; N.Ö.: conceptualization and design, acquisition of data, analysis and interpretation of data, and writing of the original draft; G.Ö.K.: conceptualization and design and writing of review and editing; E.O.: conceptualization and design and writing of review and editing. All the authors read and approved the final version of the manuscript.

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No competing interests reported.

Physical Activity Level Effect on Cognitive Level And Quality Of Life in Patients with Breast Cancer: A Case Control Study Investigation Of The Relationship Between Physical Activity Level And Quality Of Life In Patients With Breast Cancer

Status:

Version 1

Abstract

Introduction

Methods

Patients

Data collection and definitions

Data analysis

Results

Dıscussıon

Limitations:

Conclusion and Future Directions

Declarations

References

Additional Declarations

Status:

Version 1