Running head: THE EFFECT OF EXERCISE ON QOL IN BREAST CANCER PATIENTS
The Effect of Exercise on Quality of Life in Breast Cancer Patients
Meredith Blaylock
Mandy D’Amico
Ashley Pigg
Alex Rodriguez
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THE EFFECT OF EXERCISE ON QOL IN BREAST CANCER PATIENTS
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PICO
Our PICO question states, “Does a specific exercise program affect quality of life in
breast cancer patients receiving treatment?” The patient/population, “P”, for our PICO question
is breast cancer patients receiving treatment. The intervention, “I”, is a specific exercise
program. The comparison, “C”, is no specific exercise program. The outcome, “O”, is quality of
life. This question is significant to nursing practice because the quality of life of patients is a
priority in nursing care. One way nurses can help improve quality of life is by thoroughly
educating their patients on current evidenced based practices regarding quality of life. New
studies are being done investigating how exercising affects quality of life in a variety of patient
populations. One patient population that is subject to decreased quality of life is cancer patients
undergoing treatment, such as chemotherapy and radiation. In general, these patients experience
nausea, fatigue, depression, anxiety, activity intolerance, and decreased self- esteem. Breast
cancer patients have become a target population for research studies because of the increased
prevalence of breast cancer.
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Search Strategy Description
The literature search for this PICO question was executed using the following databases:
CINAHL, COCHRANE, MEDLINE, Academic Search Premier, Health Source:
Nursing/Academic Edition. Searches were made combining keywords such as breast cancer,
exercise, quality of life, chemotherapy, oncology, aerobics, strength training, regime, fatigue,
depression, appetite, sleep patterns, self-esteem, and anxiety. When combining theses keywords,
the most successful combination in generating results related to our PICO question was breast
cancer, exercise, and quality of life. Initially this search yielded 501 results. We narrowed the
results of the search by only selecting scholarly journals and changing the publication date search
criteria to include only articles published after 2002. This narrowed down the results to 224
articles. From there we read the titles and abstracts to determine the relevance to the PICO
question. After finding relevant results we determined whether the articles were strong levels of
evidence by including multiple systematic reviews, a meta-analysis of randomized controlled
trials, and a controlled trial without randomization (quasi-experimental study). We excluded all
articles that were single non-experimental studies, systematic reviews of descriptive and
qualitative studies, single descriptive or qualitative studies, and opinion articles. After reading
these articles in their entirety we determined that nine were appropriate for our use. Of the nine,
three were level I, five were level II, and one was level III. We were unsuccessful in finding
clinical practice guidelines specifically addressing exercise as an intervention in various
databases and websites such as www.ahrq.gov and www.guidelines.gov.
THE EFFECT OF EXERCISE ON QOL IN BREAST CANCER PATIENTS
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Synthesis of the Evidence
In breast cancer patients, there are many unfavorable physiological and psychosocial
changes resulting from treatment. These changes, which are associated with a decrease in
quality of life, include intense nausea, decreased cardiovascular muscular endurance, decreased
physical function and functional capacity, decreased coping ability, increased fatigue, increased
anxiety, sleep disturbances, decreased mood, and increased occurrence of depression. Research
is currently being done and collectively reviewed to determine if exercise interventions have an
effect on these unfavorable changes. While reviewing the literature, some studies have found
that exercise as an intervention during treatment improved quality of life, while some studies
contained inconsistent evidence and provided inconclusive results. The specific exercise
programs that were used as interventions included aerobic exercise, resistance training exercise,
seated exercise, and Pilates.
One randomized controlled trial found that aerobic exercise at a moderate intensity for
twenty minutes three times a week decreased nausea intensity in patients undergoing cancer
treatment (Lee, Dodd, Dibble, & Abrams, 2008). A systematic review of nine trials provided
additional evidence supporting aerobic exercise as an intervention that decreases nausea intensity
(Markes, Brockrow, & Resch, 2009). Mood, including increased happiness related to an
improved self-esteem, was found to be improved in patients who were participants of multiple
aerobic exercise intervention groups (Maryam, Fazlollah, Eesa, Ebrahim, & Abbas, 2010;
Courneya et al., 2007). In addition, one randomized controlled trial found that aerobic exercise
increased cardiovascular endurance when done thirty minutes, two to three days per week at fifty
to seventy percent of the patient’s maximum heart rate. This randomized controlled trial
concluded that the increased endurance led to an increase in coping ability and an improvement
THE EFFECT OF EXERCISE ON QOL IN BREAST CANCER PATIENTS
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in ability to perform activities of daily living (Pastakia & Kumar, 2010). A patient’s ability to
perform activities of daily living is strongly influenced by altered sleeping patterns and anxiety
related to cancer treatment, which were both decreased in the experimental groups included in
the systematic review done by Markes et al. (2009). A patient’s general quality of life, as
measured using the Quality of Life- Breast Cancer Questionnaire, also determines their ability to
perform these activities. This questionnaire was used in a quasi-experimental research study and
the results showed an overall increase in quality of life when patients participated in aerobic
exercise for three to five days a week for a total of nine weeks (Maryam et al., 2010).
While the majority of research done has focused on aerobic exercise programs, multiple
studies have sought to evaluate the effectiveness of resistance exercise training as an intervention
to improve quality of life. In one randomized controlled trial, members of the experimental
group performed nine different resistance exercises three times a week, each consisting of eight
to twelve repetitions. This intervention resulted in improved self-esteem, improved muscular
strength, and lean body mass in these patients, contributing to an increased quality of life
(Courneya et al., 2007). One experiment included in the systematic review done by Bicego et al.
(2009) evaluated resistance training done sixty minutes a day twice a week over a period of six
months. This systematic review as a whole determined that exercise as an intervention led to
decreased body weight and fatigue as well as increased overall health (Bicego et al., 2009).
Less strenuous exercise interventions such as seated exercise and Pilates were also found
to impact quality of life in breast cancer patients. One randomized controlled trial implemented
a seated exercise program, which consisted of following a videotape routine three times a week
for the experimental group. Patients in this group reported less fatigue at the end of their
chemotherapy treatments than patients in the control group who were not participating in the
THE EFFECT OF EXERCISE ON QOL IN BREAST CANCER PATIENTS
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seated exercise program. Patients in the control group experienced an accelerated decrease in
quality of life, compared to the experimental group (Headley, Ownby, & John, 2004). When
Pilates was used in one randomized controlled trial, patients performed sessions three times a
week for eight weeks. The aspects of quality of life that were evaluated were physical function,
functional capacity, and incidence of depression. The Pilates interventions was successful in
producing positive effects in these three aspects (Eyigor, Karapolat, Yesil, Urlu, & Durmaz,
2010).
While reviewing the literature, there were some studies that had inconclusive evidence
about the impact of an exercise program on quality of life. One randomized controlled trial that
included thirty minutes of moderate to vigorous activity five days a week as an intervention
found that exercise did not contribute to an improvement in overall quality of life or
psychosocial functioning (Cadmus et al., 2009). The systematic review done by Markes et al.,
which included both randomized controlled trials and non-randomized controlled trials, found no
statistically significant differences relating to the expected outcome measures of decreased
depression, increased mood, and decreased fatigue (2009). A randomized controlled trial that
compared both aerobic exercise training and resistance exercise training to no implemented
exercise interventions found that neither increased cancer specific quality of life as determined
by the researchers’ use of the Functional Assessment of Cancer Therapy-Anemia Scale
(Courneya et al., 2007). These researchers also found that no adverse effects such as
lymphedema were observed in either of the groups receiving exercise as an intervention
(Courneya et al., 2007).
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Consistency of Evidence
While a majority of the studies yielded similar results, each study was conducted
differently, using different methods and exercise interventions as well as measuring different
aspects of quality of life (QOL). These studies generally stated that exercise therapy was
beneficial to QOL for women with breast cancer receiving adjuvant therapy. There were
however, two studies done by Cadmus et al. (2009) and Markes et al. (2009) that yielded no
added benefits from exercise therapy on QOL.
All of the studies were well designed with a majority being upper levels of research. The
studies were all in the top three levels of evidence with three systematic reviews, one quasiexperimental, and the remaining randomized controlled trials. Each of the studies detailed the
process including the methods and specific exercise interventions used. Strengths and
weaknesses of the research were also addressed in each of the studies. All of the experimental
studies utilized informed consent and were approved by Institutional Review Boards or ethics
committees. These qualities attribute to the fact that these studies were all very well designed.
While each of the studies implemented a different exercise intervention and measured
different aspects of QOL, the general recommendation was that exercise can be an intervention
for breast cancer patients undergoing adjuvant therapy in order to improve QOL. Meanwhile,
there was also strong evidence that suggested that exercise did not have an effect on breast
cancer patients’ QOL, but that further research was needed.
Applying the evidence based practice recommendation of implementing exercise therapy
to breast cancer patients is beneficial to the overall health of these patients. As evidenced by
these studies, exercise therapy can improve QOL in these patients by not only decreasing fatigue
and nausea associated with chemotherapy, but by also improving patients’ moods. In addition,
THE EFFECT OF EXERCISE ON QOL IN BREAST CANCER PATIENTS
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the studies that yielded no benefits on QOL from exercise therapy stated that despite these
results, exercise has clear and important health benefits and poses no risk to the patients.
There is no evidence in any of the research that cost studies have been done. However,
exercise is a low-cost intervention as it is non-pharmacological and noninvasive.
Recommendations
 Exercise is recommended for breast cancer patient’s undergoing adjuvant therapy to improve
mood and quality of life (QOL) by increasing overall health through socialization, goal setting,
participation, decreased body weight, or decreased fatigue.
o Grade: A
o Bicego, D., Brown, K., Ruddick, M., Storey, D., Wong, C., & Harris, S. R. (2009).
Effects of exercise on quality of life in women living with breast cancer: A systematic
review. Breast Journal, 15(1), 45-51. doi:10.1111/j.1524-4741.2008.00670.x
o
Courneya, K., Segal, R., Mackey, J., Gelmon, K., Reid, R., Friedenreich, C., & ...
McKenzie, D. (2007). Effects of aerobic and resistance exercise in breast cancer
patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial.
Journal Of Clinical Oncology, 25(28), 4396-4404. doi: 10.1200/JCO.2006.08.2024
o
Eyigor, S., Karapolat, H., Yesil, H., Uslu, R., & Durmaz, B. (2010). Effects of pilates
exercises on functional capacity, flexibility, fatigue, depression and quality of life in
female breast cancer patients: a randomized controlled study. European Journal Of
Physical And Rehabilitation Medicine, 46(4), 481-487. Retrieved from
http://web.ebscohost.com.spot.lib.auburn.edu/ehost/search/advanced?sid=333e38573f8b-46ac-8594-04cb607635f7%40sessionmgr114&vid=1&hid=104
THE EFFECT OF EXERCISE ON QOL IN BREAST CANCER PATIENTS
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o Headley, J. A., Ownby, K. K., & John, L. D. (2004). The effect of seated exercise on
fatigue and quality of life in women with advanced breast cancer. Oncology Nursing
Forum, 31(5). 977-983. doi:10.1188/04.ONF.977-983
o
Jiyeon, L., Dodd, M. J., Dibble, S. L., & Abrams, D. I. (2008). Nausea at the end of
adjuvant cancer treatment in relation to exercise during treatment in patients with breast
cancer. Oncology Nursing Forum, 35(5), 830-835. doi:10.1188/08.ONF.830-835
o Maryam, A., Fazlollah, A., Eesa, M., Ebrahim, H., & Abbas, V. (2010). The effect of
designed exercise programme on quality of life in women with breast cancer receiving
chemotherapy. Scandinavian Journal Of Caring Sciences, 24(2), 251-258.
doi:10.1111/j.1471-6712.2009.00714.x
o
Pastakia, K., & Kumar, S. (2011). Exercise parameters in the management of breast
cancer: A systematic review of randomized controlled trials. Physiotherapy Research
International, 16(4), 237-244. doi:10.1002/pri.505

Exercise was not found to produce improvements in quality of life (QOL) in women with
breast cancer undergoing adjuvant therapy; however, it is recommended that further research
be done.
o
Grade: A
o Cadmus, L. A., Salovey, P., Yu, H., Chung, G., Kasl, S., & Irwin, M. L. (2009).
Exercise and quality of life during and after treatment for breast cancer: results of two
randomized controlled trials. Psycho-Oncology, 18(4), 343-352. doi:10.1002/pon.1525
o
Markes, M., Brockow, T., Resch, K. L. (2009). Exercise for women receiving
adjuvant therapy for breast cancer (review). The Cochrane Database of Systemic
Reviews. (1). 1-39. doi: 10.1002/14651858.CD005001.pub2
THE EFFECT OF EXERCISE ON QOL IN BREAST CANCER PATIENTS
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References
Bicego, D., Brown, K., Ruddick, M., Storey, D., Wong, C., & Harris, S. R. (2009). Effects of exercise on
quality of life in women living with breast cancer: A systematic review. Breast Journal, 15(1),
45-51. doi:10.1111/j.1524-4741.2008.00670.x
Cadmus, L. A., Salovey, P., Yu, H., Chung, G., Kasl, S., & Irwin, M. L. (2009). Exercise and quality of
life during and after treatment for breast cancer: results of two randomized controlled trials.
Psycho-Oncology, 18(4), 343-352. doi:10.1002/pon.1525
Courneya, K., Segal, R., Mackey, J., Gelmon, K., Reid, R., Friedenreich, C., & ... McKenzie, D. (2007).
Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant
chemotherapy: a multicenter randomized controlled trial. Journal Of Clinical Oncology, 25(28),
4396-4404. doi: 10.1200/JCO.2006.08.2024
Eyigor, S., Karapolat, H., Yesil, H., Uslu, R., & Durmaz, B. (2010). Effects of pilates exercises on
functional capacity, flexibility, fatigue, depression and quality of life in female breast cancer
patients: a randomized controlled study. European Journal Of Physical And Rehabilitation
Medicine, 46(4), 481-487. Retrieved from
http://web.ebscohost.com.spot.lib.auburn.edu/ehost/search/advanced?sid=333e3857-3f8b-46ac8594-04cb607635f7%40sessionmgr114&vid=1&hid=104
Headley, J. A., Ownby, K. K., & John, L. D. (2004). The effect of seated exercise on fatigue and quality
of life in women with advanced breast cancer. Oncology Nursing Forum, 31(5). 977-983.
doi:10.1188/04.ONF.977-983
Jiyeon, L., Dodd, M. J., Dibble, S. L., & Abrams, D. I. (2008). Nausea at the end of adjuvant cancer
treatment in relation to exercise during treatment in patients with breast cancer. Oncology
THE EFFECT OF EXERCISE ON QOL IN BREAST CANCER PATIENTS
11
Nursing Forum, 35(5), 830-835. doi:10.1188/08.ONF.830-835
Markes, M., Brockow, T., Resch, K. L. (2009). Exercise for women receiving adjuvant therapy for breast
cancer (review). The Cochrane Database of Systemic Reviews. (1). 1-39. doi:
10.1002/14651858.CD005001.pub2
Maryam, A., Fazlollah, A., Eesa, M., Ebrahim, H., & Abbas, V. (2010). The effect of designed exercise
programme on quality of life in women with breast cancer receiving chemotherapy. Scandinavian
Journal Of Caring Sciences, 24(2), 251-258. doi:10.1111/j.1471-6712.2009.00714.x
Pastakia, K., & Kumar, S. (2011). Exercise parameters in the management of breast cancer: A systematic
review of randomized controlled trials. Physiotherapy Research International, 16(4), 237-244.
doi:10.1002/pri.505