The effect of exercise intensity on physiological and psychological

Transcription

University of Notre Dame Australia
ResearchOnline@ND
Theses
2014
The effect of exercise intensity on physiological and psychological outcomes in
breast and prostate cancer survivors: a controlled study
Eric Martin
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Martin, E. (2014). The effect of exercise intensity on physiological and psychological outcomes in breast and prostate cancer
survivors: a controlled study (Doctor of Philosophy (PhD)). University of Notre Dame Australia. http://researchonline.nd.edu.au/
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The Effect of Exercise Intensity on Physiological and
Psychological Outcomes in Breast and Prostate Cancer
Survivors: A controlled study.
Eric Alexander Martin
M.A, B.A.
A thesis submitted for the degree of
Doctor of Philosophy
School of Health Sciences
The University of Notre Dame, Australia
February 2014
Declaration of Authorship
This thesis is my own work and contains no material which has been accepted for the
award of any degree or diploma in any other institution.
To the best of my knowledge, the thesis contains no material previously published or
written by another person, except where due reference is made in the text of the thesis.
___________________25/2/2014_____
Eric Martin
Date
ii
Abstract
Introduction
Research has identified a need to explore the components of exercise
prescription for cancer survivors, particularly the most effective exercise intensity. The
main purpose of this research was to examine whether exercise intensity modulates a
range of physiological and psychological outcomes for breast and prostate cancer
survivors. The primary outcomes were related to peak oxygen consumption (VO2peak)
and quality of life (QOL). VO2peak is a highly sensitive measure that indicates overall
health. QOL references the general wellbeing of individuals, and is an outcome of great
importance in cancer rehabilitation research.
Pilot Study
A pilot study involving breast cancer survivors (n = 19) and prostate cancer
survivors (n = 12) was undertaken to determine the feasibility of delivering an eightweek group exercise and supportive group psychotherapy (SGP) intervention.
Physiological (weight, body composition, cardiorespiratory endurance, and lower body
strength) and QOL (using the Functional Assessment of Cancer Therapy questionnaire)
outcomes were measured pre- and post-intervention in order to monitor program
efficacy. The participants also provided feedback during group interviews after program
completion in order to determine the acceptability of the program. Interpretative
phenomenological analysis was used to analyse the feedback, determine the
acceptability of the program and inform the main study design.
The pilot study recorded 90% retention and over 80% attendance rates for both
components, indicating that the intervention was feasible for both breast and prostate
cancer survivors. The results of the objective assessments of cardiorespiratory fitness
and muscular strength indicated a basic efficacy of the intervention; however, they
iii
highlighted possible differences in response between the cancer types. In the feedback
sessions, the participants described the contributions of both exercise and SGP to their
feelings of wellbeing. The main themes that emerged were that the exercise facilitated
the counselling sessions, and that the group bonding and sharing were the most
important aspects of the program. The main changes to methodology from the pilot to
the main study were to include a more sensitive cardiopulmonary fitness test, add
measures of exercise motivation and physical activity levels, and add a follow-up
assessment four months after completion of the post-intervention.
Main Study Methods
In the main phase of the research, breast cancer survivors (n = 72) and prostate
cancer survivors (n = 87) were recruited. Those who enrolled in the group exercise and
SGP intervention were randomised to a higher intensity group (HIG) (75 to 80%
VO2peak and 65 to 80% one repetition maximum [1RM], n = 40) or lower intensity
group (LIG) (60 to 65% VO2peak and 50 to 65% 1RM, n = 44). A control group of
breast and prostate cancer survivors (n = 75) followed usual care. All the participants
were assessed before and after the eight-week intervention or usual care. The
intervention participants were followed up four months after intervention completion to
monitor their ongoing physiological and psychological parameters and physical activity
levels. The physiological assessments included cardiorespiratory fitness (ramped
bicycle protocol), body composition (skinfolds), flexibility (shoulder goniometry and sit
and reach test) and muscular strength and endurance (one repetition maximum leg press,
push ups, and plank). The psychological assessments included questionnaires to assess
QOL (Functional Assessment of Cancer Therapy), fatigue (Piper Fatigue Scale) and
exercise motivation (Behavioural Regulations in Exercise Questionnaire version 2). The
physiological assessments included cardiorespiratory fitness (ramped bicycle protocol),
iv
body composition (skinfolds), flexibility (shoulder goniometery and sit and reach test)
and muscular strength and endurance (one repetition maximum leg press, push ups, and
plank). The psychological assessments included questionnaires to assess QOL
(Functional Assessment of Cancer Therapy), fatigue (Piper Fatigue Scale) and exercise
motivation (Behavioural Regulations in Exercise Questionanire version 2). Their
physical activity levels were also assessed via the International Physical Activity
Questionnaire.
Results
Program attendance for the HIG and LIG was approximately 90% for all
planned sessions. The HIG had a high compliance (90%) to their target aerobic
intensity; however, this was significantly lower (p < 0.001) than the LIG (97%). The
LIG and HIG had similar increases in VO2peak (1.7 and 2.2 mL/kg/min, respectively),
both of which were greater than the control group (p < 0.001). From post-intervention to
follow up, the HIG increased 0.2 mL/kg/min while the LIG decreased 1.3 mL/kg/min (p
= 0.021). The HIG decreased their body fat by 2.3%, which was significantly more than
the control group (-0.3%; p = 0.002) but similar to the LIG (-1.1%; p = 0.37). The HIG
increased the number of push ups they could perform by 6.6, which was significantly
greater (p < 0.001) than both the LIG (+3.0) and the control group (+1.8). At follow up,
the HIG and LIG both maintained their push up performance (p = 0.96). On the leg
press test, the HIG increased their 1RM by 24.6 kg, which was significantly more than
the control group (+8.9 kg, p = 0.007) but similar to the LIG (+14.4 kg, p = 0.16). From
post-intervention to follow up, analyses indicated the HIG and LIG did not significantly
differ on change in leg press 1RM (+3.8 kg and -8.6 kg, respectively; p = 0.08). No
adverse events occurred in response to the higher intensity training.
v
There were no differences between the intervention arms and control group on
changes in QOL from baseline to post-intervention. Similarly, there were no differences
between the intervention groups on maintenance of QOL. Both intervention arms
improved their exercise motivation specifically derived from meeting goals while the
control group did not (LIG +0.4 points, HIG +0.3 points, control group +0.0 points; p =
0.004). The HIG maintained their motivation derived from both meeting goals and
enjoying exercise at the follow up (no change for both), while the LIG returned to
baseline levels (-0.3 points and -0.4 points, respectively; p = 0.047 and 0.007,
respectively). All groups began with and maintained low levels of fatigue. All groups
reported high levels of physical activity at baseline, and the intervention participants
maintained these high levels at follow up. Although the participants maintained many
improvements from post-intervention to follow up, regardless of intensity prescription,
there were no further improvements from post-intervention to follow up. The breast and
prostate cancer survivors attended and complied similarly with the intervention, and
responded similarly on most physiological and psychological measures. The exceptions
were that the breast cancer survivors improved their upper body muscular endurance
and lower body strength by a greater magnitude than did the prostate cancer survivors.
At the follow up, there were no significant differences in changes on any outcomes
between the cancer types.
Discussion
The results of this study suggest that higher intensity exercise provided greater
long-term benefits to the breast and prostate cancer survivors for cardiorespiratory
fitness, body composition and exercise motivation. Improved cardiorespiratory fitness
and body composition have been directly linked to disease-free survival. There were no
differences between the exercise and control groups for QOL or fatigue, thus indicating
vi
that this intervention did not successfully improve these psychological outcomes. The
high level of physical activity by the control participants was unexpected, and probably
mitigated some of the expected responses from the intervention. The breast and prostate
cancer survivors responded similarly to the intervention on most physiological and
psychological parameters.
Conclusion
The results of this study indicate that exercising at 70% of VO2peak and 65 to
80% 1RM provided greater long-term cardiorespiratory, body composition and exercise
motivation maintenance than exercising at 61% VO2peak and 50 to 65% 1RM for breast
and prostate cancer survivors. However, there were no differences between these
exercise intensity levels for long-term influence on QOL. Measurable benefits can be
achieved by exercising at higher intensities than previously prescribed.
vii
Acknowledgements
Thank you to my support: Patrick, Rene, Adam, Clay, Sally, Rod, Brooke, Jeremy,
Leon, Coop, Ethan, Marc, British Mark, Lucie, Anthony, Ramiro, Mel, and all my
friends and family.
Thank you to all the men and women who participated in this study.
Thank you to Jo Millios for her help and encouragement.
I would like to extend special thanks to all the people who worked with me to deliver
this intervention:
Gordon Smith for saving this research by volunteering so much of his time to counsel
the men.
Mark Peterson for keeping all the equipment working.
The School of Counselling and all the counsellors who volunteered their time to help
the participants: Mark Pearson, Helen Wilson, Cathie Smith, Anne Pickering, Martin
Philpott, Alistair Bain, Norah McMenamin, Claire Walsh, Philippa Gavranich, Gretta
Lee, and Linda Walker
I would like to thank my supervisors, Dr Fiona Naumann and Professor Beth Hands, for
helping me complete this thesis, as well as Professor Naomi Trengrove, Professor Helen
Parker, and Dr Caroline Bulsara for their guidance.
I would like to acknowledge Hospital Benefits Fund and Sports Medicine Australia for
their grant funding of this research.
viii
Contents
Declaration of Authorship ............................................................................................... ii
Abstract ............................................................................................................................iii
Acknowledgements ........................................................................................................ viii
Contents ........................................................................................................................... ix
List of Tables .................................................................................................................xiii
List of Figures ............................................................................................................... xvi
List of Abbreviations ................................................................................................... xviii
Chapter 1: Introduction .................................................................................................. 1
1.1 The Importance of Cardiorespiratory Fitness in Cancer Survivorship ................... 1
1.2 The Importance of Quality of Life in Cancer Survivorship .................................... 2
1.3 The Current State of Exercise Oncology ................................................................ 3
1.4 Research Gap 1: Exercise Intensity......................................................................... 4
1.5 Research Gap 2: Physical Activity Maintenance .................................................... 7
1.6 Research Gap 3: Differences between Breast and Prostate Cancer ........................ 8
1.7 Group Exercise and Supportive Group Psychotherapy Intervention .................... 10
1.8 Purpose .................................................................................................................. 10
1.9 Significance ........................................................................................................... 11
1.10 Research Questions ............................................................................................. 11
1.11 Delimitations ....................................................................................................... 12
1.12 Limitations .......................................................................................................... 12
Chapter 2: Literature Review ........................................................................................ 14
2.1 Cancer Survivorship .............................................................................................. 14
2.2 Long-term Health Consequences of Prostate and Breast Cancer Treatments ....... 16
2.3 Health Benefits of Exercise ................................................................................... 19
2.4 Physical Activity and Cancer Prevention .............................................................. 23
2.4.1 Primary Prevention ........................................................................................ 24
2.4.2 Secondary and Tertiary Prevention ................................................................ 28
2.4.3 Exercise Intensity, Cardiorespiratory Fitness, and Cancer Risk and
Survival .......................................................................................................... 28
2.5 Quality of Life of Cancer Survivors ...................................................................... 35
2.5.1 Quality of life specific to breast and prostate cancer survivors. .................... 40
2.5.2 Exercise and quality of life. ........................................................................... 41
2.5.2.1 Exercise intensity and quality of life. ...................................................... 43
2.5.2.2 Exercise and cancer-related fatigue. ...................................................... 44
2.5.3 Counselling and quality of life. ...................................................................... 45
2.5.4 Combined exercise and counselling interventions and quality of life. .......... 48
2.6 Current Exercise Guidelines for Cancer Survivors ............................................... 50
2.7 High Intensity Exercise and Cancer Survivors ..................................................... 53
2.7.1 Efficacy and risks of high intensity exercise in cancer survivors. ................. 53
2.7.2 Exercise intensity and immune function in cancer survivors. ....................... 56
2.7.3 High compared to low to moderate intensity exercise. .................................. 58
2.8 Exercise Motivation and Adherence in Cancer Survivors .................................... 61
2.8.1 Measuring exercise motivation. ..................................................................... 69
2.8.2 Improving exercise adherence. ...................................................................... 72
ix
2.9 Gender Differences and Exercise .......................................................................... 74
2.10 Summary ............................................................................................................. 77
Chapter 3: Pilot Study ................................................................................................... 79
3.1 Methods ................................................................................................................. 81
3.1.1 Participant recruitment. .................................................................................. 81
3.1.2 Outcomes. ...................................................................................................... 82
3.1.2.1 Feasibility................................................................................................ 82
3.1.2.2 Physiological assessments. ..................................................................... 82
3.1.2.3 Quality of life. ......................................................................................... 83
3.1.3 Intervention. ................................................................................................... 83
3.1.4 Procedures. ..................................................................................................... 84
3.1.5 Qualitative analysis. ....................................................................................... 85
3.1.6 Statistical analysis. ......................................................................................... 87
3.2 Results ................................................................................................................... 88
3.2.1 Participant characteristics. ............................................................................. 88
3.2.2 Feasibility. ...................................................................................................... 89
3.2.3 Outcome measures. ........................................................................................ 89
3.2.4 Narrative feedback. ........................................................................................ 90
3.2.4.1 An opportunity to explore and redefine self-identity............................... 91
3.2.4.2 Support to succeed, despite prior failures. ............................................. 92
3.2.4.3 The importance of exercise variety. ........................................................ 93
3.2.4.4 Value that the combined exercise and counselling model offered
participants............................................................................................. 96
3.2.4.5 Changing perceptions of counselling. ..................................................... 98
3.2.4.6 The importance of participating in the intervention as a group. .......... 100
3.2.4.7 The importance of maintaining exercise behaviours. ........................... 101
3.3 Discussion ........................................................................................................... 102
3.3.1 Feasibility and basic efficacy. ...................................................................... 102
3.3.2 Self-identity, prior experiences and overall benefits. .................................. 102
3.3.3 Importance of intervention components. ..................................................... 103
3.3.4 Maintenance of benefits and behaviours. ..................................................... 103
3.4 Changes to Main Study ....................................................................................... 103
Chapter 4: Main Study Methods ................................................................................. 106
4.1 Participant Recruitment ....................................................................................... 106
4.2 Measures ............................................................................................................. 107
4.2.1 Valdity and Reliability of Physiological Assessments ................................ 107
4.2.2 Resting vitals and anthropometrics. ............................................................. 109
4.2.3 Flexibility. .................................................................................................... 110
4.2.4 Cardiopulmonary fitness. ............................................................................. 110
4.2.5 Muscular strength and endurance. ............................................................... 111
4.2.6 Questionnaires. ............................................................................................. 112
4.2.7 Aerobic compliance and workload. ............................................................. 116
4.2.8 Resistance training workload. ...................................................................... 116
4.2.9 Rating of perceived exertion. ....................................................................... 116
4.2.10 Safety and adherence. ................................................................................ 117
4.3 Group Exercise and SGP Intervention ................................................................ 117
4.3.1 Exercise intensity assignment. ..................................................................... 118
4.3.2 Program design and behaviour change and sustainability. .......................... 118
4.3.3 Exercise prescription. ................................................................................... 119
x
4.3.3.1 Aerobic exercise prescription. .............................................................. 120
4.3.3.2 Resistance exercise prescription. .......................................................... 121
4.3.4 Supportive group psychotherapy. ................................................................ 122
4.4 Usual Care ........................................................................................................... 123
4.5 Procedures ........................................................................................................... 123
4.6 Ethics ................................................................................................................... 126
4.7 Data Analysis ...................................................................................................... 126
4.7.1 Sample size. ................................................................................................. 126
4.7.2 Statistical analyses. ...................................................................................... 127
4.7.2.1 Research questions. ............................................................................... 127
Chapter 5: Results ....................................................................................................... 131
5.1 Participant Recruitment and Retention ............................................................... 131
5.1.1 Intervention participants. ............................................................................. 131
5.1.2 Control participants. ..................................................................................... 132
5.2 Participant Characteristics ................................................................................... 134
5.3 Attendance, Compliance, and Safety .................................................................. 142
5.3.1 Program attendance. ..................................................................................... 142
5.3.2 Aerobic compliance. .................................................................................... 142
5.3.3 Resistance workload. ................................................................................... 145
5.3.4 Rating of perceived exertion. ....................................................................... 146
5.3.5 Safety. .......................................................................................................... 146
5.4 Outcome Differences between Groups ............................................................... 146
5.4.1 Physiological outcomes................................................................................ 148
5.4.1.1 Anthropometrics. ................................................................................... 148
5.4.1.2 Flexibility. ............................................................................................. 150
5.4.1.3 VO2peak................................................................................................. 152
5.4.1.4 Muscular strength and endurance. ....................................................... 155
5.4.2 Psychological outcomes. .............................................................................. 158
5.4.2.1 Quality of life. ....................................................................................... 158
5.4.2.2 Exercise motivation. .............................................................................. 163
5.4.2.3 Fatigue. ................................................................................................. 167
5.5 Outcome Differences between Cancer Types ..................................................... 169
5.6 Physical Activity Levels ..................................................................................... 176
5.6.1 Physical activity barriers and choices. ......................................................... 180
5.7 Summary ............................................................................................................. 181
Chapter 6: Discussion ................................................................................................. 186
6.1 Key Findings ....................................................................................................... 186
6.2 Intervention Design ............................................................................................. 187
6.2.1 Participant recruitment and attendance. ....................................................... 187
6.2.2 Acceptance. .................................................................................................. 188
6.2.3 Compliance. ................................................................................................. 188
6.3 Effectiveness of Intervention and Intensity Differences ..................................... 192
6.3.1 Physiological outcomes................................................................................ 192
6.3.1.1 Body composition. ................................................................................. 193
6.3.1.2 Flexibility. ............................................................................................. 194
6.3.1.3 Cardiorespiratory fitness. ..................................................................... 194
6.3.1.4 Muscular strength and endurance. ....................................................... 196
6.3.2 Psychological outcomes. .............................................................................. 197
6.3.2.1 Quality of life. ....................................................................................... 197
xi
6.3.2.2 Exercise motivation. .............................................................................. 199
6.3.2.3 Fatigue. ................................................................................................. 201
6.4 Gender Differences in Intervention Response .................................................... 202
6.5 Physical Activity Levels at Follow Up ............................................................... 205
6.5.1 Barriers to exercise....................................................................................... 207
6.6 Study Strengths ................................................................................................... 208
6.6.1 Novel measures. ........................................................................................... 208
6.6.2 Novel intervention........................................................................................ 209
6.7 Study Limitations ................................................................................................ 209
6.7.1 Study design and control group behaviour. ................................................. 210
6.7.2 Self-report of physical activity levels. ......................................................... 210
6.7.3 Intervention compliance. .............................................................................. 211
6.7.4 Baseline characteristics of participants. ....................................................... 211
6.8 Summary ............................................................................................................. 213
Chapter 7: Summary and Conclusions ...................................................................... 214
7.1 Key Findings and Conclusions............................................................................ 215
7.2 Recommendations for Clinical Practice .............................................................. 217
7.3 Recommendations for Future Research .............................................................. 218
7.4 Closing Remarks ................................................................................................. 220
References..................................................................................................................... 221
Appendix A. Information Sheets and Informed Consent Forms ............................... 279
Appendix B. Demographics Questionnaire ................................................................. 288
Appendix C. Copies of Standardized Questionnaires ................................................. 290
Appendix D. Semi Structured Interview Questions for Narrative Feedback ............. 305
Appendix E. Raw Group Means at all Assessments, Divided by Cancer Types ........ 307
Appendix F. Example Training Log ........................................................................... 314
Appendix G. Exercise Sessions .................................................................................... 316
Appendix H. Initial Resistance Training Load Guidelines ........................................ 329
Appendix I. CPET calibration procedures .................................................................. 331
xii
List of Tables
Table 1 Major Needs of Cancer Survivors ...................................................................... 39
Table 2 Summary of Exercise Guidelines for Cancer Survivors .................................... 52
Table 3 Summary of Exercise Behaviour Theories ......................................................... 63
Table 4 Summary of Interventions to Change the Physical Activity Levels of Breast
and Prostate Cancer Survivors, which are Grounded in a Behavioural
Theory ............................................................................................................ 64
Table 5 Exercise Motivation (BREQ-2) Scores of Western Australian Breast Cancer
Survivors Performing Different Levels of Physical Activity .......................... 71
Table 6 Pilot Study Participant Characteristics ............................................................. 89
Table 7 Baseline and Post-intervention Outcome Scores from Pilot Study .................... 90
Table 8 Summary of Validity and Reliability of Physiological Assessments ................ 108
Table 9 Questionnaire Summary, Validity, Reliability and Clinically Meaningful
Change ......................................................................................................... 114
Table 10 Sample Exercise Session ................................................................................ 120
Table 11 Prescribed Aerobic Exercise Intensity and Progression in Relative and
Absolute Measures ....................................................................................... 121
Table 12 Program Schedule .......................................................................................... 125
Table 13 Comparison of Cancer Types for Age and Months Post-treatment ............... 134
Table 14 Prostate Cancer Survivors’ Treatment and Demographic Characteristics .. 136
Table 15 Breast Cancer Survivors’ Treatment and Demographic Variables ............... 137
Table 16 Baseline Physiological Measures for Cancer Type within Group ................. 138
Table 17 Baseline Quality of Life Outcome Measures for Cancer Type within Group 139
Table 18 Baseline Physical Activity and Exercise Motivation Outcome Measures for
Cancer Type within Group ........................................................................... 140
Table 19 Baseline Fatigue Outcome Measures for Cancer Type within Group ........... 141
Table 20 Participant Attendance at Exercise and SGP Sessions for Each Group ....... 142
Table 21 Achieved Aerobic Workloads and Compliance during Intervention ............. 143
Table 22 Characteristics of Participants (n = 72) Who Completed the Follow-up
Assessment ................................................................................................... 147
Table 23 Comparison between Participants who Dropped and Completed Follow
Up Assessment .............................................................................................. 147
xiii
Table 24 Adjusted Mean Changes between Assessment Periods for Weight (kg) and
Body Fat (%) ................................................................................................ 149
Table 25 Adjusted Mean Changes between Assessment Periods for Sit and Reach
(cm from Toes) ............................................................................................. 150
Table 26 Adjusted Mean Changes at both Assessment Periods on Shoulder ROM
(Degrees) ...................................................................................................... 151
Table 27 Adjusted Mean Changes in VO2peak (mL/kg/mind) between Assessment
Periods ......................................................................................................... 153
Table 28 Adjusted Mean Changes in Push-ups (Repetitions) between Assessment
Periods ......................................................................................................... 155
Table 29 Adjusted Mean Changes in Plank Time (Seconds) between Assessment
Periods ......................................................................................................... 156
Table 30 Adjusted Mean Changes in Leg Press 1RM (kg) between Assessment
Periods ......................................................................................................... 157
Table 31 Adjusted Mean Change on Quality of Life Outcomes between Assessment
Periods ......................................................................................................... 159
Table 32 Adjusted Mean Change on Prostate Cancer–specific Quality of Life
Outcomes between Assessment Periods ....................................................... 160
Table 33 Adjusted Mean Change on Breast Cancer–specific Quality of Life
Outcomes between Assessment Periods ....................................................... 162
Table 34 Adjusted Mean Change in Exercise Motivation Outcomes between
Assessment Periods ...................................................................................... 164
Table 35 Adjusted Mean Change in Fatigue Outcomes between Assessment Periods . 168
Table 36 Attendance and Performance for Prostate and Breast Cancer Intervention
Participants .................................................................................................. 169
Table 37 Adjusted Changes for Cancer Types on Physiological Outcomes between
Table 38 Adjusted Changes for Cancer Types on Quality of Life Outcomes between
Table 39 Adjusted Changes for Cancer Types on Exercise Motivation Outcomes
between Assessment Periods ........................................................................ 175
Table 40 Adjusted Changes for Cancer Types on Fatigue Outcomes between
Table 41 Physical Activity Levels at Baseline and Follow Up as Measured by IPAQ . 178
xiv
Table 42 Physical Activity Levels at Baseline and Follow Up as Measured by IPAQ,
with Outliers Removed ................................................................................. 179
Table 43 Reasons for Decreasing Physical Activity and Types of Activities
Performed Among Follow-up Participants (n = 72) ................................... 180
Table E1 Raw Outcomes (M, SD) for Prostate Cancer Survivors ................................ 308
Table E2 Raw Outcomes (M, SD) for Breast Cancer Survivors .................................. 311
xv
List of Figures
Figure 1. Position for plank exercise. ........................................................................... 112
Figure 2. Participant recruitment flow diagram. ........................................................... 133
Figure 3. Scatter plot of breast and prostate cancer survivors’ aerobic compliance,
divided by assigned exercise intensity. ........................................................ 144
Figure 4. Scatter plot of achieved relative aerobic intensity according to assigned
exercise intensity. ......................................................................................... 145
Figure 5. Raw group means for BF% at baseline, post-intervention and follow up. .... 148
Figure 6. Raw group means for sit and reach at baseline, post-intervention and
follow up. ..................................................................................................... 150
Figure 7. Raw group means for shoulder ROM at baseline, post-intervention and
follow up. ..................................................................................................... 151
Figure 8. Raw group means for VO2peak at baseline, post-intervention and follow
up. ................................................................................................................. 152
Figure 9. Scatter plot of relationship between relative aerobic exercise intensity
achieved and change in VO2peak. ................................................................ 154
Figure 10. Raw group means for push-ups at baseline, post-intervention and follow
up. ................................................................................................................. 155
Figure 11. Raw group means for plank time at baseline, post-intervention and
follow up. ..................................................................................................... 156
Figure 12. Raw group means for leg press 1RM at baseline, post-intervention and
follow up. ..................................................................................................... 157
Figure 13. Raw group means for general QOL at baseline, post-intervention and
follow up. ..................................................................................................... 158
Figure 14. Raw group means for prostate cancer–specific additional concerns and
FACT-P scores at baseline, post-intervention and follow up. ..................... 160
Figure 15. Raw group means for breast cancer–specific additional concerns and
FACT-B scores at baseline, post-intervention and follow up. ..................... 161
Figure 16. Raw group means for RAI scores at baseline, post-intervention and
follow up. ..................................................................................................... 163
Figure 17. Raw group means for identified regulation scores at baseline, postintervention and follow up. .......................................................................... 165
xvi
Figure 18. Raw group means for intrinsic regulation scores at baseline, postintervention and follow up. .......................................................................... 166
Figure 19. Raw group means for PFS scores at baseline, post-intervention and
follow up. ..................................................................................................... 167
Figure 20. Raw group means for leg press 1RM (kg) for (a) prostate and (b) breast
cancer survivors at baseline, post-intervention and follow up. .................... 170
Figure 21. Raw group means for push-ups (repetitions) for (a) prostate and (b)
breast cancer survivors at baseline, post-intervention and follow up. ......... 171
Figure 22. Raw group means for introjected regulation for (a) prostate and (b) breast
Figure 23. Raw group means for emotional wellbeing for (a) prostate and (b) breast
xvii
List of Abbreviations
1RM
one repetition maximum
ACSM
American College of Sports Medicine
ADT
androgen deprivation therapy
ANCOVA
analysis of covariance
ANOVA
analysis of variance
BF%
body fat percentage
BMI
body mass index
BPM
beats per minute
BREQ-2
Behavioural Regulation in Exercise Questionnaire Version 2
CPET
cardiopulmonary exercise test
CVD
cardiovascular disease
FACIT
Functional Assessment of Chronis Illness Therapy
FACT-B
Functional Assessment of Cancer Therapy—Breast
FACT-G
Functional Assessment of Cancer Therapy—General
FACT-P
Functional Assessment of Cancer Therapy—Prostate
GP
general practitioner
HIG
higher intensity group
HR
heart rate
IPAQ
International Physical Activity Questionnaire
LIG
lower intensity group
MET
metabolic equivalent of task
PAG
physical activity guidelines
PAR-Q
physical activity readiness questionnaire
PFS
Piper Fatigue Scale
xviii
QOL
quality of life
RAI
relative autonomy index
ROM
range of motion
RPE
rating of perceived exertion
SDT
self-determination theory
SGP
supportive group psychotherapy
TTM
transtheoretical model of behaviour change
UK
United Kingdom
USA
United States of America
VO2peak
peak oxygen consumption
xix
Chapter 1: Introduction
Every year, more people complete cancer treatments; however, that is only an
early milestone in their cancer survivor journey. Accompanying survival are the
possible side effects from acute and ongoing treatments, which may continue to
diminish physical function and quality of life (QOL) for years after treatment
completion (McNeely et al., 2010; Schmitz et al., 2010; Van Weert et al., 2005).
Exercise can ameliorate some of the physical symptoms of these side effects and
improve QOL (Hayes, Spence, Galvao & Newton, 2009; Schmitz et al., 2010).
Psychological counselling interventions may also improve QOL by improving
emotional and psychological wellbeing in cancer survivors (Blake-Mortimer, GoreFelton, Kimerling, Turner-Cobb & Spiegel, 1999; Rehse & Pukrop, 2003; Ross,
Boesen, Dalton & Johansen, 2002). Recent research has provided evidence that
combining exercise and psychological components in a multimodal intervention can
lead to additive benefits for breast cancer survivors’ QOL (Naumann et al., 2012a).
These recent studies prompted the rationale for the design and implementation of the
group exercise and supportive group psychotherapy (SGP) intervention used in this
research. The conclusions of the American College of Sports Medicine (ACSM)
guidelines on exercise for cancer survivors state that more research is needed to
optimise exercise prescription for this population (Schmitz et al., 2010). The present
research study focused on one key variable of exercise prescription—intensity—within
the context of its multimodal rehabilitation intervention.
1.1 The Importance of Cardiorespiratory Fitness in Cancer
Survivorship
Assessing cardiorespiratory fitness by measuring peak rate of oxygen
consumption (VO2peak) has been described as the best surrogate for overall health and
1
longevity (Mancini, LeJemtel & Aaronson, 2000). Research has shown that VO2peak is
the most important factor for predicting cardiovascular disease (CVD) risk and all-cause
mortality (Blair et al., 1996). Systemic cancer treatments, such as chemotherapy, can
both directly and indirectly decrease cardiorespiratory fitness (Dempsey, 2008) and
subsequently increase the risks of CVD and death (Laukkanen, Rauramaa, Makikallio,
Toriola & Kurl, 2011; Mancini et al., 2000). Laukkanen et al. (2011) demonstrated a
dose–response relationship between increases in VO2peak and cancer survival.
Therefore, assessing VO2peak in cancer survivors can provide an objective measure by
which to judge the success and overall health effects of an exercise intervention (Jones,
Eves, Haykowsky, Joy & Douglas, 2008).
1.2 The Importance of Quality of Life in Cancer Survivorship
Fallowfield (2002), Nayfield et al. (1992) and Sloan et al. (2002) identified four
dimensions contributing to QOL: physical functionality, psychological functionality,
social functionality and emotional wellbeing. Loss of physical function due to treatment
side effects has been rated as the most important detriment to QOL both during and
after cancer treatments (Courneya et al., 2003b). This loss creates psychological distress
for cancer survivors and may contribute to depression (Courneya et al., 2003b; Strong et
al., 2008). In a review of observational studies, Zainal et al. (2013) found that about
22% of breast cancer survivors were categorized as having clinical depression. The
interaction between depression and impairment of well-being is reciprocal in cancer
survivors, with one major contributor being pain experienced after treatment (for
example, pain in the shoulder girdle after breast cancer surgery and/or radiation therapy)
(Baune, Caniato, Garcia-Alcaraz, & Berger, 2008; Strong et al., 2008). The connection
between mental and physical causes and symptoms requires that both areas of wellbeing be addressed to properly help cancer survivors (Baune et al., 2008; Strong et al.,
2
2008). Losses in either physical or psychological function can make cancer survivors
feel socially isolated (Binkley et al., 2012). Impairment of any of the four dimensions
can negatively affect the others, and subsequently affect total QOL (Ferrell, Grant,
Funk, Otis-Green & Garcia, 1997). Even breast cancer survivors who have been
disease-free for five years still rate themselves as having impaired physical wellbeing
compared to healthy women (Helgeson & Tomich, 2005). While cancer treatments
extend quantity of life, they do not necessarily mean survivors will have good QOL
(Blake-Mortimer et al., 1999). For these reasons, QOL has become a major targeted
endpoint in research regarding cancer survivors.
1.3 The Current State of Exercise Oncology
The ACSM guidelines on exercise for cancer survivors promote participation in
exercise during and post-treatment. However, detail in exercise prescription is lacking
in terms of what is suitable for cancer patients and what benefits more specific exercise
programming may elicit (Schmitz et al., 2010). In general, all exercise programming
variables—including volume, mode and intensity—need to be scrutinised to determine
best-practice exercise prescriptions for cancer populations. A major gap highlighted by
the ACSM guidelines is the need to clarify the dose–response of exercise intensity for
targeted outcomes, such as QOL, cardiovascular function and fatigue (Schmitz et al.,
2010).
Recent epidemiological evidence suggests that high intensity exercise may have
greater benefits for cancer survivors by increasing survival rates, as compared to low or
moderate intensity exercise (Friedenreich, McGregor, Courneya, Angyalfi & Elliott,
2004; Giovannucci, Liu, Leitzmann, Stampfer & Willett, 2005; Hamer, Stamatakis &
Saxton, 2009; Laukkanen et al., 2011). Additionally, moderate intensity exercise
increases cancer survivors’ QOL more than low intensity exercise (Ferrer, Huedo-
3
Medina, Johnson, Ryan & Pescatello, 2011). However, it is still unknown whether high
intensity exercise provides any greater benefit to QOL than does moderate intensity
exercise.
The present research aimed to prospectively examine if exercising at 75 to 80%
of VO2peak and 65 to 80% of one repetition maximum (1RM), within the context of a
group exercise and SGP intervention, would enhance cancer survivors’ QOL,
physiological function, psychological function and physical activity levels to a greater
extent than exercising at 60 to 65% VO2peak and 50 to 65% 1RM. Two other major
gaps in the literature identified by Ferrer et al. (2011) were ways to motivate cancer
survivors to engage in and sustain exercise, and whether any differences in exercise
response exist between male and female cancer survivors.
1.4 Research Gap 1: Exercise Intensity
Research has determined that high intensity aerobic exercise provides greater
VO2peak improvements and health benefits than low to moderate intensity aerobic
exercise in healthy adults (Swain & Franklin, 2006). However, the evidence is less
conclusive among cancer survivors. Some studies have shown that high intensity
exercise can improve a range of health and QOL outcomes in cancer survivors
(Adamsen et al., 2009; De Backer et al., 2008; Quist et al., 2006), but less is known
about the tolerance, adaptability and safety of using high intensity exercise in this
population (Adamsen et al., 2009; De Backer et al., 2008; Jones, Peppercorn, Scott &
Battaglini, 2010b; Quist et al., 2006). Additionally, no other published research has
compared high intensity and low to moderate intensity exercise in cancer survivors.
The interest in high intensity exercise in cancer survivors stems from a series of
epidemiological studies that highlighted the importance of intensity, rather than volume,
of exercise for cancer risk and survival (Friedenreich et al., 2004; Giovannucci et al.,
4
2005; Hamer et al., 2009; Laukkanen et al., 2011). However, in these studies, the
intensity and volume were sometimes intertwined because the measure of physical
activity used incorporated both aspects. Generally, epidemiologists use the metabolic
equivalent of task (MET) system, which is an absolute measure of energy expenditure
and is based on the Ainsworth compendium (Ainsworth et al., 2000). This is not
actually a measure of exercise intensity, although there are some obvious correlations
(Swain & Franklin, 2006). The MET system describes the level of metabolic activity or
oxygen consumption of a physical activity as a multiple of a person’s resting VO2.
Based on population means, basal MET level is pinned at 3.5 mL/kg/min (Norton,
Norton & Sadgrove, 2010). High intensity exercise is described as exercising over six
MET (Ainsworth et al., 2000; Ferrer et al., 2011).
The differences in the ways epidemiologists and exercise physiologists describe
exercise level and intensity should be considered when interpreting these results. In
contrast to MET, exercise physiologists prescribe exercise in relative terms, instead of
absolute terms (Swain & Franklin, 2006), and consider high intensity aerobic exercise
as approximately 80% of VO2max, or at and above a person’s anaerobic threshold
(Mann, Lamberts & Lambert, 2013). The difference between using VO2 and MET is
best illustrated by comparing examples of individuals with low and high levels of
cardiovascular fitness. An unfit individual may exercise at 80% VO2max and not reach
six MET—that is, they cannot exercise at a level that is more than six times greater than
their resting VO2. In contrast, a very fit individual may be able to exercise at six MET
and be well below 80% VO2max (Byrne, Hills, Hunter, Weinsier & Schutz, 2005;
Norton et al., 2010). Importantly, for an unfit individual, exercising at a high relative
intensity will provide cardiovascular improvements, even if the absolute level is
considered low by some (Swain & Franklin, 2006).
5
In a recent meta-analysis, Ferrer et al. (2011) attempted to determine the exercise
intervention characteristics that most influenced QOL outcomes for cancer survivors.
The authors found that intensity, as quantified by MET, predicted improvements in
QOL as measured by questionnaires such as the FACT-G, EORTC QLQ-30, and SF-36
(β = 0.25, p = 0.03). Exercising aerobically at six MET (labelled moderate intensity) led
to significant improvements in QOL, while four MET (labelled low intensity) was not
sufficient to make significant changes in QOL. However, few studies targeted the
aerobic exercise at six MET, with the average intensity being 4.2 MET. For resistance
training, the targeted MET levels were even lower, with an average of 2.5 MET. Based
on these studies’ bias towards low to moderate intensity exercise, Ferrer et al. (2011)
recommended that a study was warranted that compared high and low to moderate
intensity aerobic and resistance exercise for improving QOL.
This meta-analysis (Ferrer et al., 2011), combined with the ACSM Roundtable
on Exercise Guidelines for Cancer Survivors (Schmitz et al., 2010), highlighted the
need to identify whether a dose–response effect of exercise occurs among cancer
survivors. The ACSM panel have acknowledged that research in the area of exercise
programming for cancer survivors is in the developmental stage. They have identified
significant research knowledge gaps regarding the dose of exercise required to ensure
cancer survivors receive safe and effective exercise prescription for targeted endpoints,
such as VO2peak and QOL. Based on this gap in knowledge, the current research
proposed to examine whether exercising at a higher intensity than normally prescribed
would enable breast and prostate cancer survivors to improve and maintain their
cardiorespiratory fitness and QOL to a greater extent than exercising at the normal low
to moderate intensity.
6
1.5 Research Gap 2: Physical Activity Maintenance
Recent research found that as many as 70% of cancer survivors do not perform
sufficient daily physical activity to achieve the recommended health guidelines
(Blanchard, Courneya & Stein, 2008). The majority of cancer survivors significantly
decrease their level of physical activity after diagnosis, with a return to pre-diagnosis
physical activity levels being highly unlikely (Peeters et al., 2009). The prolific work of
Courneya and his colleagues has examined aspects of physical activity, exercise barriers
and the personal characteristics of cancer survivors that contribute to the survivors’
ability or motivation to begin and maintain an exercise regime (Blanchard et al., 2003;
Blanchard et al., 2008; Courneya et al., 2009; Courneya, Jones, Mackey & Fairey, 2006;
Milne, Gordon, Guilfoyle, Wallman & Courneya, 2007; Milne, Wallman, Gordon &
Courneya, 2008b; Milne, Wallman, Guilfoyle, Gordon & Courneya, 2008c; Rhodes,
Courneya & Bobick, 2001; Rogers et al., 2011; Rogers, Courneya, Shah, Dunnington &
Hopkins-Price, 2007; Rogers, McAuley, Courneya & Verhulst, 2008; Thorsen,
Courneya, Stevinson & Fossa, 2008; Vallance, Plotnikoff, Karvinen, Mackey &
Courneya, 2010). This collection of work identified many characteristics of successful
exercise maintainers, especially self-efficacy and previous level of physical activity.
However, further research is needed to determine the key facilitators to improving
cancer survivors’ exercise motivation.
The present research examined the effect of exercise intensity on exercise
motivation and physical activity levels, beyond the duration of a structured intervention.
Research has shown that people who enjoy exercise perform more physical activity
(Dacey, Baltzell & Zaichkowsky, 2008) and that enjoyment is a key component of
intrinsic exercise motivation (Ingledew & Markland, 2008). Additionally, some
researchers have identified that people self-select the exercise intensity they find most
7
enjoyable, whether this be high intensity (Bartlett et al., 2011; Duncan, Hall, Wilson &
Jenny, 2010) or low to moderate intensity (Parfitt & Hughes, 2009). What is unknown is
whether prescribing high intensity exercise to cancer survivors will affect their
enjoyment of exercise, and subsequently influence their exercise motivation.
1.6 Research Gap 3: Differences between Breast and Prostate Cancer
While prior studies have used survivors of a variety of cancer types to test the
efficacy of an intervention, few studies have explicitly compared the response of breast
and prostate cancer survivors to the same intervention. In a review, Ferrer et al. (2011)
found that women may improve their QOL more than men through participating in an
exercise intervention (p < 0.01). However, they speculated that the imbalance in volume
of research between male and female cancers may have skewed their results. When
other factors in a multivariate analysis, such as length of intervention or exercise
intensity, were accounted for, cancer type became ‘less directly connected to QOL
changes’ (Ferrer et al., 2011, p. 41). The exercise oncology literature is dominated by
breast cancer research, while other cancers have received less attention. For example, 42
(54%) of the studies reviewed by Ferrer et al. (2011) used only breast cancer in their
samples, while just 6 (8%) focused only on prostate cancer, despite the populations of
survivors of both diseases being approximately equal (Australian Institute of Health and
Welfare & Australasian Association of Cancer Registries, 2010). The participants in the
remaining studies included mixed groups of cancer survivors with a wide variety of
diagnoses. These two cancers represent the largest segment of the cancer population in
Australia that research and interventions can help (Australian Institute of Health and
Welfare & Australasian Association of Cancer Registries, 2010). Studies examining
exercise in cancer patients should make direct comparisons between male and female
cancer survivors in order to establish whether differences in physiological responses to
8
training programs exist between genders, which may necessitate different guidelines for
each gender or cancer group (Ferrer et al., 2011).
A first step in this study was to determine if one prescriptive intervention model
would be equally acceptable and effective for breast and prostate cancer survivors, or if
separate programs should be developed for each population. Second, as the SGP was an
important component of the intervention, it was necessary to determine if this model
was as effective for prostate cancer survivors as it was for breast cancer survivors. The
results of this study’s prior research indicated that combining exercise and
psychological counselling modalities had an additive improvement for breast cancer
survivors’ QOL compared to the benefit derived from the single modalities (Naumann
et al., 2012a). Participating in group exercise and SGP was also found to be as equally
effective as individual participation (Naumann et al., 2012b). However, this research
had only been trialled in breast cancer survivors. Thus, one aim of the present research
was to extend the multimodal intervention to prostate cancer survivors in order to
determine feasibility and efficacy.
Prior research has shown that men are reluctant to engage in psychological
interventions after cancer treatment (Boudioni et al., 2001; Carmack Taylor et al., 2006;
Eakin & Strycker, 2001; Kaplan, 2008; Krizek, Roberts, Ragan, Ferrara & Lord, 1999;
Nekolaichuk, Cumming, Turner, Yushchyshyn & Sela, 2011; Petersson, Berglund,
Brodin, Glimelius & Sjödén, 2000; Plass & Koch, 2001; Sherman et al., 2007; Steginga
et al., 2008). This reluctance is caused by a sense of stigma against seeking mental
health services, or a view that these services are not needed, which is compounded by a
lack of awareness and support from healthcare providers for engaging prostate cancer
survivors in psychological health services (Boudioni et al., 2001; Eakin & Strycker,
2001; Kaplan, 2008; Krizek et al., 1999; Plass & Koch, 2001; Sherman et al., 2007;
9
Steginga et al., 2008). Based on these gaps, a pilot study was conducted to determine
the feasibility and acceptability of delivering a group exercise and SGP intervention to
both breast and prostate cancer survivors.
1.7 Group Exercise and Supportive Group Psychotherapy Intervention
The intervention used in this research comprised an eight-week group exercise
and SGP program, delivered three days per week. The exercise sessions lasted one hour,
and were held on all three days. The exercise intervention was grounded in the
transtheoretical model of behaviour change (TTM) to support the exercise behaviour
change goals of the intervention. The SGP session was held once each week for 90
minutes. In the main phase of the research, the participants were randomised to exercise
either at a higher (75 to 80% VO2peak and 65 to 80% 1RM) or lower (60 to 65%
VO2peak and 50 to 65% 1RM) intensity. The SGP portion of the intervention was the
same for both exercise groups and was delivered by counsellors from The University of
Notre Dame Australia School of Counselling. It should be noted here that SGP, group
interaction and incorporation of the TTM were constants between the intensity groups.
The only manipulated variable was the exercise intensity at which each group
performed.
1.8 Purpose
The primary purpose of this research was to examine the responses and
maintenance of breast and prostate cancer survivors to a combined short-term group
exercise and SGP intervention on VO2peak, QOL and physical activity levels. Of
specific interest were the differences in responses to either higher intensity (75 to 80%
VO2peak and 65 to 80% 1RM) or lower intensity (60 to 65% VO2peak and 50 to 65%
1RM) exercise. The secondary purpose was to examine whether there were any
10
differences in program compliance or change in outcomes between the breast and
prostate cancer survivors.
1.9 Significance
This study was significant because it sought to address three research knowledge
gaps on how exercise intensity, within a multimodal cancer rehabilitation program, can
influence physiological, psychological and behavioural outcomes in two gender-specific
cancer survivor populations. The results may help inform the development of exercise
guidelines for cancer survivors with respect to the exercise intensity needed to achieve
certain benefits, and regarding whether different guidelines may be needed for prostate
and breast cancer survivors.
1.10 Research Questions
This study’s research questions were as follows:
1. Is a group exercise and SGP intervention feasible and acceptable to breast
and prostate cancer survivors?
2. Are breast and prostate cancer survivors able to adhere to and comply with
an exercise program at an intensity of 75 to 80% VO2peak and 65 to 80%
1RM?
3. Are there differences in the physiological and psychological responses
between cancer survivors participating in an exercise program at 60 to 65%
VO2peak and 50 to 65% 1RM, 75 to 80% VO2peak and 65 to 80% 1RM, or
usual care?
4. Are there differences in the sustainability of the physiological and
psychological parameters at follow up between the breast and prostate cancer
survivors who completed the program exercising at a higher intensity,
compared to those who exercised at a lower intensity?
11
5. Are there differences in the physiological and psychological responses and
program adherence between the breast and prostate cancer survivors to the
same group exercise and SGP intervention?
6. Are there differences in physical activity levels four months after a shortterm intervention between breast and prostate cancer survivors who
completed the program exercising at a higher intensity, compared to those
who exercised at a lower intensity?
1.11 Delimitations
The delimitations of this study were as follows:

The participants in this study were men and women, aged 25 to 80 years old,
who had completed treatments for prostate and breast cancer, respectively.
The results of this study may not be applicable to other cancer populations or
those still undergoing treatment.

The participants had Stage I, II or III invasive breast or prostate cancer.
Since Stage IV cancers were excluded, the results of this study may not
apply to men and women who suffer from metastatic prostate or breast
cancer, respectively.
1.12 Limitations
The limitations of this study were as follows:

Differing stages of the disease; types of treatment; time post-treatment and
the physiological, psychological and physical activity levels between the
groups may have biased the results.

The sample may not have been representative of the population. A sample of
convenience was recruited from people who were able to enrol in the group
exercise and counselling intervention at the specific times and dates offered.
12
Likewise, the control group was a convenience sample. Enrolment in this
study was voluntary; therefore, only participants who felt they would benefit
from the group exercise and SGP may have self-selected to participate.

The researcher was not blinded to patient treatment arm allocation during the
post-intervention and follow-up assessments, which may have introduced
assessment bias. The researcher also performed all assessments and exercise
intervention delivery, which may have created bias.

As participants were recruited in groups over the course of a year, it is
possible there was a seasonal effect for physical activity levels at the time of
enrolment.

Participants self-reported physical activity levels using a questionnaire; selfreporting questionnaires always introduce a bias for accuracy.
13
Chapter 2: Literature Review
In this chapter, the exercise oncology literature is reviewed to examine the issues
related to cancer survivorship and to highlight the importance of rehabilitation
interventions to assist the growing cancer survivor population. A large portion of the
review focuses on the health and QOL benefits of exercise for cancer survivors.
Different interventions designed to improve cancer survivors’ QOL are examined. The
link between exercise intensity and cancer survival is explored, as these studies provide
the rationale for examining exercise intensities and indicate the implications of
employing higher intensity exercise for cancer survivors. Further, the effect of high
intensity exercise for cancer survivors and other chronic disease populations is
examined. As the maintenance of exercise in this population was one measure of the
success of the intervention, an examination of how exercise intensity may affect
exercise motivation—and therefore the sustainability of exercise among cancer
survivors—is also presented. This chapter concludes with a comparison of responses to
exercise between genders, as the two cancer types examined in the present study were
gender-specific.
2.1 Cancer Survivorship
Improvements in the screening and treatment of cancers has created a large and
growing population of survivors, estimated to be over 300,000 in Australia (Eakin et al.,
2007) and almost seven million worldwide (Ferlay et al., 2008). Cancer is Australia’s
leading burden of disease, accounting for 19% of the total burden (Australian Institute
of Health and Welfare & Australasian Association of Cancer Registries, 2010) and
costing the country AUD$16 million per year in healthcare for breast cancer alone
(Stephenson, Bauman, Armstrong, Smith & Bellow, 2000). Costs to the patients
themselves can reach over AUD$12,500 in the first year alone (Pisu et al., 2010).
14
The five-year survival rate of cancer is calculated as the number of people who
are still alive five years after diagnosis, compared to cases matched by age and gender
in the general population. The five-year survival rate has been used as the benchmark
for accepting that a cancer survivor is now disease-free, although reoccurrence past the
five-year mark is possible (Australian Institute of Health and Welfare & Australasian
Association of Cancer Registries, 2010). Breast and prostate cancer represent the most
frequently diagnosed cancers in Australian women and men, respectively (Australian
Institute of Health and Welfare & Australasian Association of Cancer Registries, 2010).
Over 130,000 Australian women are survivors of breast cancer, which reflects an
improvement of the five-year survival rates to 88%, compared to 72% 20 years ago
(Australian Institute of Health and Welfare & Australasian Association of Cancer
Registries, 2010). Prostate cancer survival rates are even higher than breast cancer, with
ninety-three per cent of men surviving 10 years after treatment, however survival rates
drop to 77% after 15 years (Australian Institute of Health and Welfare & Australasian
Association of Cancer Registries, 2010).
Although survival rates are increasing, disease-free survivorship still has a
negative effect on health. This negative effect can stem from lingering side effects
associated with primary and follow-up treatment of breast and prostate cancer. Followup treatment includes continued hormonal treatments for up to five years, such as
Tamoxifen or aromatase inhibitors for breast cancer and androgen deprivation therapy
for prostate cancer (Australian Institute of Health and Welfare & Australasian
Association of Cancer Registries, 2010).
15
2.2 Long-term Health Consequences of Prostate and Breast Cancer
Treatments
Prostate cancer is most commonly treated by combinations of surgery, androgen
deprivation therapy (ADT) and radiation therapy. Treatment side effects can include
reduced libido, sexual function, lean muscle mass, strength, bone density, physical
functionality, cognitive function, and testosterone to castrate levels (Antonelli,
Freedland & Jones, 2009; Beehler, Wade, Kim, Steinbrenner & Wray, 2009; CulosReed, Robinson, Lau, O’Connor & Keats, 2007; Galvao et al., 2006; Galvao et al.,
2008; Galvao, Taaffe, Spry & Newton, 2007; Hakimian et al., 2008; Segal et al., 2003).
Concurrently, there may be an increase in adipose mass, insulin resistance, negative
lipoprotein profiles and fatigue. These risks are especially prevalent in cancer survivors
undergoing ADT because this treatment has been shown to directly result in insulin
resistance, which leads to adverse metabolic profiles (Basaria, Muller, Carducci, Egan
& Dobs, 2006; Braga-Basaria et al., 2006; De Haas et al., 2010; Hakimian et al., 2008).
The combined influence of these side effects can contribute to the development of
severe depression that compromises a patient’s psychological and physical function
(Galvao et al., 2006). Radiation therapy leads to an increased incidence and worsening
of erectile dysfunction, which is a risk factor for developing CVD (Antonelli,
Freedland, et al., 2009; Beard et al., 1997). Treatment side effects reduce functionality
and therefore independence in prostate cancer survivors, and negatively affect their
QOL (Antonelli, Freedland et al., 2009; Beehler et al., 2009; Culos-Reed et al., 2007;
Galvao et al., 2007; Galvao et al., 2008; Segal et al., 2003). Patients have reported that
the side effects are worse than the prostate cancer itself, and these side effects therefore
need to be addressed through supportive interventions, such as exercise and
psychological counselling (Culos-Reed et al., 2007).
16
Many of these side effects contribute to an increased risk of cardiovascular
morbidity and mortality, diabetes and metabolic syndrome (De Haas et al., 2010).
Recent research suggests that prostate cancer comorbidities, particularly CVD, cause
more deaths than prostate cancer itself (Antonelli, Freedland et al., 2009; Beehler et al.,
2009; Fouad et al., 2004). Additonally, having two or more comorbid conditions
increases the risk of dying 3.5 times compared to prostate cancer survivors without
comorbid conditions, even accounting for age, stage, and grade of cancer (Houterman,
Janssen-Heijnen, Hendrikx, Berg, & Coebergh, 2006). Prostate cancer survivors in
Australia are approximately 33% more likely than the healthy population of dying from
non-cancer causes, in particular cardiorespiratory disease (Baade, Fritschi, & Eakin,
2006).
Surgery, chemotherapy and radiotherapy are the most common acute treatments
for breast cancer. Hormone therapy can be used for acute treatment, but is more
commonly used to prevent reoccurrence (Boyer, 1999). The physical side effects from
the cancer and its treatment can include fatigue, nausea, muscle cachexia, fat and weight
gain, increased risk of osteoporosis, early onset of menopause, impaired cardiovascular
and pulmonary function, impaired balance and cardiotoxicity. The psychological side
effects can include depression, emotional and psychological disturbances, and feeling a
loss of hope and control (Battaglini et al., 2007; Berg, Wood-Dauphinee, Williams &
Maki, 1992; Boyer, 1999; Cho, Yoo & Kim, 2006; Courneya & Karvinen, 2007;
Demark-Wahnefried, Rimer & Winer, 1997b; Keays, Harris, Lucyshyn & MacIntyre,
2008; Newton & Galvao, 2008; Twiss et al., 2009). These side effects can linger for
years beyond treatment completion and can contribute to a worsening QOL, thereby
necessitating the need to assist patients after they complete their active treatment phase.
17
One specific side effect of breast cancer treatment, which poses a particular
concern for exercise interventions, is lymphoedema. A recent meta-analysis estimated
that 21.4% of all breast cancer survivors would suffer unilateral arm lymphoedema
(DiSipio, Rye, Newman, & Hayes, 2013). Arm lymphoedema impairs shoulder girdle
range of motion and is painful enough to negatively impact QOL (Hayes et al., 2012).
Exercise usually does not increase the risk of developing or worsening lymphoedema in
breast cancer survivors (Cavanaugh, 2011; Cormie, Galvao, Spry, & Newton, 2013),
and typically has been shown to help alleviate lymphoedema (Hayes et al., 2012).
Additionally, Cormie et al. (2013) showed that neither light nor heavy resistance
training increased swelling in breast cancer survivors with lymphoedema immediately
post exercise or 24 and 72 hours later.
Following acute treatment completion, many women continue with hormone and
targeted therapies, such as Tamoxifen, aromatase inhibitors and herceptin. Tamoxifen
has been one of the most commonly prescribed hormone therapies. It is prescribed for
up to five years after surgery and is used to block oestrogen, with the goal of preventing
tumour reoccurrence (Veronesi, Boyle, Goldhirsch, Orecchia & Viale, 2005). Common
side effects of Tamoxifen include fatigue, hot flushes, mood swings, increased risk of
uterine cancer and cardiotoxicity (Dempsey, 2008). Aromatase inhibitors are used after
or instead of Tamoxifen, but can lead to arthritis and osteoporosis (Veronesi et al.,
2005). While both hormone treatments may contribute to osteoporsis risk, aromatase
inhibitors lead to a significantly greater reduction in bone mineral density and
subsequently higher bone fracture rate than Tamoxifen (Becker, Lipscombe, Narod,
Simmons, Anderson, & Rochon, 2012). The continued affliction of these side effects
constitute the need for cancer survivors to still receive care up to five years beyond
18
acute treatment completion, such as that provided by exercise physiologists and
counsellors.
In summary, breast and prostate cancer survivors often experience decreased
physical function and impaired mental function and wellbeing after treatment. Cancer
survivors are at increased risk of diseases such as CVD, diabetes and arthritis due to
age, changes in lifestyle and treatment side effects (Schmitz et al., 2010; Van Weert et
al., 2005). Some of the main physiological problems survivors face from primary and
ongoing treatments include a loss of cardiovascular capacity, decrease in muscle mass
with concurrent increases in fat mass, and loss of flexibility (Schmitz et al., 2010).
Losses in shoulder flexibility and function are especially pronounced in breast cancer
survivors as a side effect of surgery and radiotherapy (McNeely et al., 2010). For
prostate cancer survivors, incontinence and sexual dysfunction are the main
physiological consequences of treatment (Treiyer, Anheuser, Bütow & Steffens, 2011).
All of these sequelae contribute to survivors’ loss of QOL, which needs to be actively
addressed through a combination of exercise and psychological interventions.
2.3 Health Benefits of Exercise
Physiologically, exercise can increase muscle cross-sectional areas, muscle
glycogen stores, and oxygen delivery and use, which increases an individual’s total
functional capacity across all components of fitness (Costill, Coyle, Fink, Lesmes &
Witzmann, 1979). Cardiorespiratory function measured by VO2 is the most important
fitness component for general health and longevity, both in cancer and healthy
populations (Blair et al., 1996; Laukkanen et al., 2011). The mechanisms for the cardioprotective effects of chronic aerobic exercise training include improved cardiac
antioxidant capacity; increased glutathione uptake in the myocardium; habituation of the
myocardium to oxidative stress, along with reducing levels of oxidative stress caused by
19
aging; and increasing the synthesis of heat-shock proteins by up-regulating the
activation levels of heat-shock transcription factor one (Ascenaso, Ferreira &
Magalhaes, 2007).
The cardio-protective benefits of exercise are especially important for breast
cancer patients who receive anthracycline chemotherapies (Dempsey, 2008) and
prostate cancer survivors who undergo ADT (Hakimian et al., 2008). Anthracycline
chemotherapies can cause cardiotoxicity, which leads to decreased left ventricular
ejection fraction and eventually congestive heart failure (Dempsey, 2008; Gianni et al.,
2001). Losses in cardiac function of up to 50% have been observed following
chemotherapy (Gianni et al., 2001). Fortunately, a prospective randomised controlled
trial has shown that exercise can prevent losses in VO2peak caused by anthracycline
chemotherapy (Courneya et al., 2007b). In prostate cancer survivors, ADT decreases
cardiac function directly by causing arterial stiffness and decreasing testosterone, and
indirectly by causing insulin resistance, a loss of skeletal muscle and an increase in
dyslipidaemia and subsequent adiposity (Hakimian et al., 2008; Shahani, Braga-Basaria
& Basaria, 2008). Exercise may help prevent or reverse almost all of these detrimental
effects of ADT (Galvao et al., 2007; Galvao, Taaffe, Joseph & Newton, 2009).
Exercise in general provides a range of health benefits, although these may
differ according to the intensity. High intensity aerobic exercise provides greater cardioprotective benefits than low or moderate intensity exercise. The mechanisms by which
high intensity aerobic exercise provides superior cardiorespiratory function include
greater increases in VO2max, superoxide dismutase, insulin sensitivity and high density
lipoproteins; greater decreases in systolic and diastolic blood pressure, fasting glucose
levels, cholesterol and triglycerides; and reduced incidence of type 2 diabetes (Ascenaso
et al., 2007; Swain & Franklin, 2006).
20
While cardiorespiratory capacity is the most important component of fitness,
body composition has received an almost equal amount of attention for its contribution
to cancer mortality (Dal Maso et al., 2008; Gong, Agalliu, Lin, Stanford & Kristal,
2007; Wright et al., 2007). A major side effect of cancer treatment is a decrease in basal
metabolic rate, with a concurrent increase in adiposity, which worsens the cancer
prognosis (Beehler et al., 2009; Briganti et al., 2013; Demark-Wahnefried et al., 1997a;
Gong et al., 2007; Nichols et al., 2009). Cancer treatments—especially hormonal
treatments such as ADT or Tamoxifen—cause increases in body fat as high as 14% after
one year of treatment (Galvao et al., 2009; Keogh & MacLeod, 2012; Rooney & Wald,
2007; Visovsky, 2006). High levels of body fat increase the risk of developing
metabolic disease, CVD or a reoccurrence of cancer.
Nichols et al. (2009) found that breast cancer survivors who increased their
weight after diagnosis increased their risk of all-cause mortality at a rate of 12% for
every five kilograms gained. Obesity increases CVD and mortality risk by increasing
aortic stiffness, blood glucose levels, reactive oxygen species production, lipid
peroxidation, oxidative protein carbonylation, adipokines; decreasing lysyl oxidase
activity, mitochondrial respiratory function; and contributing to muscle cachexia
through infiltration and skeletal muscle mTOR hyperactivation (Chen et al., 2013; Lutz
& Quinn, 2012; Raza, John & Howarth, 2012). Exercise can help manage body
composition by reducing chronic inflammation associated with adipose tissue (You,
Arsenis, Disanzo & Lamonte, 2013). The mechanisms that regulate this effect include
increasing production of myokines, locally reducing adipose tissue inflammation,
systemically reducing leukocyte adhesion and cytokine production, and increasing basal
metabolism and subsequently lipolysis (Hansen, Meeusen, Mullens & Dendale, 2012;
You et al., 2013).
21
Body composition is best managed through exercise by combining aerobic and
resistance training (Tambalis, Panagiotakos, Kavouras & Sidossis, 2009; Visovsky,
2006). Additionally, high intensity exercise has been demonstrated as being more
effective for improving body composition, as evidenced by greater increases in high
density lipoproteins, fat oxidation and blood glucose regulation, and greater decreases in
plasma triglycerides (Boutcher, 2011; Colberg et al., 2010; Knechtle, Muller & Knecht,
2004; Tambalis et al., 2009). The long-term body composition benefits of high intensity
exercise should not be confused with the acute impairment of fatty acid oxidisation by
skeletal muscle (Horowitz & Klein, 2000). In fact, high intensity exercise has been
shown to be less effective than moderate intensity exercise for increasing lipolysis
during an acute bout of exercise (Horowitz & Klein, 2000; Lira et al., 2012). It is the
chronic adaptations to high intensity aerobic and resistance exercise that make it
beneficial for combating obesity, while regular moderate aerobic exercise is ineffective
(Boutcher, 2011; Tambalis et al., 2009).
Increases in body fat often occur simultaneously with losses in skeletal muscle,
and subsequently strength (Goodpaster, Kelley, Thaete, He & Ross, 2000; Koster et al.,
2010). Additionally, cancer survivors suffer from age and treatment-induced sarcopenia
(Al-Majid & Waters, 2008; Neil, Klika, Garland, McKenzie & Campbell, 2013; Tisdale,
1999; Visovsky, 2006). Much of the loss in muscle mass and strength in cancer
survivors is a result of disuse, often in response to fatigue (Neil et al., 2013). However,
cancer also directly leads to muscle wasting through increasing muscle protein
degradation, while inhibiting protein synthesis by increased activity of the ATPubiquitin-proteasome pathway (Al-Majid & Waters, 2008; Tisdale, 1999).
Observational research has determined that breast and prostate cancer survivors
experience a 20 to 25% loss in muscular strength and up to a 45% loss of muscular
22
endurance due to treatment side effects (Alt, Gore, Montagnini & Ng, 2011; Harrington
et al., 2011; Merchant, Chapman, Kilbreath, Refshauge & Krupa, 2008; Tisdale, 1999).
Resistance training is the main mode of exercise to increase muscle mass and
strength and counteract muscle wasting (ACSM et al., 2009; Glover & Phillips, 2010;
Peterson, Rhea & Alvar, 2005). Resistance training stimulates anabolic processes by
three main mechanisms: mechanical tension, muscle damage and metabolic stress
(Schoenfeld, 2010). The pathways that lead from these stimuli to, ultimately,
hypertrophy via increased sarcomeres and myofibrils are regulated by an array of
enzymes and hormones. Briefly, the stress that resistance training places on skeletal
muscle up-regulates protein synthesis to rebuild damaged muscle and prepare the body
to respond to further stresses (Schoenfeld, 2010).
Novice exercisers can experience improvements in muscular strength through
low or moderate intensity resistance training (ACSM, 2009; Peterson et al., 2005;
Schoenfeld, 2010). However, these increases may be largely neurological, rather than
hypertrophic, improvements (Schoenfeld, 2010). To increase muscle mass, an
appropriate progression to higher intensity resistance training is necessary (ACSM,
2009; Fry, 2004; Peterson et al., 2005; Schoenfeld, 2010). While cancer survivors may
not need to increase muscle mass to the same degree as a bodybuilder or athlete, the
large loss in muscle mass, especially caused by ADT or chemotherapy, warrants
hypertrophy training (Al-Majid & Waters, 2008; Galvao et al., 2007).
2.4 Physical Activity and Cancer Prevention
Several epidemiological studies have examined the association between physical
activity levels and risks of cancer diagnosis, all-cause mortality and cancer-specific
mortality. This section of the review will first highlight the summarized evidence for
primary and secondary prevention of breast and prostate cancer through physical
23
activity. Then it will focus on six particular studies that attempted to tease out the
specific effect of exercise intensity, rather than total physical activity, on cancer
prevention and management (Friedenreich et al., 2004; Giovannucci et al., 2005;
Hamer et al., 2009; Irwin et al., 2008; Laukkanen et al., 2011; West-Wright et al.,
2009).
2.4.1 Primary Prevention
A recent literature review summarized the evidence for the effect of exercise to decrease
the risk of people developing cancer (Kruk & Czerniak, 2013). They found the most
conclusive evidence to link exercise to the primary prevention of colorectal,
postmenopausal breast, and endometrial cancers, with suggestive evidence to support
this link for cancers of the, prostate, lung, ovary, pancreous, gastrointestinal organs, and
premenopausal breast cancer.
Specific to breast cancer, a dose-response between physical activity and primary
prevention has been observed, with the most active women have a 22-25% reduction in
breast cancer risk compared to the least active (Friedenreich et al., 2010; Kruk &
Czerniak, 2013; Volaklis, Halle, & Tokmakidis, 2013). However, one new study places
some doubt upon what has been considered an agreed upon preventative effect (Hartz &
He, 2013). Hartz and He (2013) assessed 800 potential risk factors for breast cancer, to
determine if any factors previously unstudied may influence the accepted risk model.
An interesting and unexpected outcome of their study was to find that exercise no
longer significantly predicted breast cancer risk. This study will lead to a review and
possible revisions of recommendations for physical activity among women to help
prevent breast cancer, however, for now it is recommended that women perform four to
seven hours of moderate to vigorous physical activity per week to enjoy these protective
benefits. It should be noted that physical activity performed after the age of 50 may be
24
more important to breast cancer prevention than that done earlier in life (Friedenreich et
al., 2010). Additionally, there are some specific populations for whome physical activity
may have a stronger preventative effect, including women who are postmenopausal,
normal weight, and have no family history. There are conflicting results as to whether
hormone-receptor status mediates the effect of physical activity on breast cancer
(Friedenreich et al., 2010).
The mechanisms of how exercise helps prevent breast cancer are becoming better
understood. Physical activity can modify sex steroid hormones, insulin resistance,
metabolic hormones, and inflammation markers in a manner that reduces breast cancer
growth and recurrence (Alegre, Knowles, Robison, & O’Neil, 2013; Volaklis et al.,
2013). Exercise can also regulate the behaviour of macrophages to inhibit tumor growth
(Goh, Kirk, Lee, & Ladiges, 2012). Lastly, exercise helps prevent breast cancer via
helping weight management, as the upregulation of leptin and insulin-like growth
factors which accompany obesity have been linked to breast cancer cell growth (Alegre
et al., 2013). In contrast to the understanding and agreement of if and how physical
activity prevents breast cancer, studies in prostate cancer have not produced as uniform
results.
The most recently published systematic reviews and meta-analyses all agree that the
evidence to link physical activity and the prevention of prostate cancer is contradictory,
limited, and suggestive (Friedenreich et al., 2010; Heitkamp & Jelas, 2012; Liu et al.,
2011; Young-McCaughan, 2012). The most recent of these reported that, out of 22
epidemilogical studies of physical activity and prostate cancer risk, 12 found a positive
protective effect, nine found no association, and one indicated that physical activity
increased prostate cancer risk (Young-McCaughan, 2012). Overall, these reviews and
meta-analyses propose that total physical activity confers a 10-20% reduction of
25
prostate cancer incidence (Friedenreich et al., 2010; Liu et al., 2011; YoungMcCaughan, 2012). In their discussions, the authors offered explanations as to why a
stronger and more consistent effect has not been observed. One major factor was the
measurement of physical activity, both in terms of how it was measured and type of
activity. Many of the studies used retrospective self report questionnaires and asked
participants to recall their lifetime physical activity, which has an inherent margin of
error (Friedenreich et al., 2010). In contrast, prospective studies have consistently
shown a preventative effect of physical activity for prostate cancer (Giovannuci et al.,
2005; Singh et al., 2013). Additionally, many studies examine total physical activity
levels, when the type of physical activity (i.e. recreational versus occupational) may
influence the preventative effect for prostate cancer; however, the evidence is again
inconclusive. One review described that only three out of eight studies showed that
occupational physical activity was significantly associated with reduced incidence of
prostate cancer. In contrast, a meta-analysis found a significant reduction in prostate
cancer risk by 19% through occupational activity as opposed to a non-signficant 5%
reduction through recreational physical activity. Rather than type, it may be that
intensity of physical activity is the more important factor for prostate cancer prevention
(Heitkamp & Jelas, 2012). Intensity, rather than total volume of physical activity, has
been shown in individual studies (Friedenreich et al., 2004; Giovannucci et al., 2005)
and a meta-analysis (Heitkamp & Jelas, 2012) to be the discriminating factor in
determining if physical activity prevented prostate cancer. Future studies should
endeavour to propsectivelly measure physical activity levels, or better yet actual fitness
(Betof, Dewhirst, & Jones, 2013), to determine physiological intensity independent of
volume to confirm these initial findings.
26
Other factors that seem to significantly mediate the association between physical
activity and prostate cancer risk are race (Singh et al., 2013), having advanced versus
early prostate cancer (Antonelli, Jones, et al., 2009), and being younger than 65 years
old (Liu et al., 2011). Two review articles discussed how it may not be the physical
activity itself, but the weight management achieved through physical activity, that
determines the risk of prostate cancer (Liu et al., 2011; Young-McCaughan, 2012).
Young-McCaughan (2012) concluded that a better understanding of the pathology and
progression of prostate cancer, including identifying significant biomarkers of its
progression, are needed to conclusively answer the question: does physical activity
prevent prostate cancer? Additionally, Friedenreich et al. (2010) point out the added
difficulty that many men die with undiagnosed prostate cancer present, which could
possibly be skewing all attempts at answering this question, because there are
potentially many men counted in these analyses as not having prostate cancer who just
did not know they had prostate cancer.
Compared to breast cancer, little is known about the mechanisms by which exercise
effects prostate cancer, however, a recent study has provided some proposed
mechanisms (Rundqvist et al., 2013). Rundqvist and colleagues (2013) collected blood
samples from healthy young males before and after different intensities of cycling
exercise, and injected these into prostate cancer cell cultures. The study operationally
defined the resting blood samples as “rest serum” and the post-exercise blood samples
as “exercise serum.” Prostate cancer cell growth was significantly inhibited when
exposed to exercise serum compared to rest serum (p < 0.05). Further tests indicated
that the reduced growth was due to inhibition of cancer cell proliferation, as opposed to
stimulation of apoptosis. These findings provide an initial pathway for research to
continue on to explore how exercise may acutely help humans stave off prostate cancer.
27
2.4.2 Secondary and Tertiary Prevention
The recent review by Betof and colleagues (2013) provides a thorough and succinct
explanation of how exercise can help prevent cancer progression or recurrence. These
mechanisms are similar to those that have been found to prevent initial breast cancer
tumor development (Volaklis et al., 2013), and include modulating metabolic and sexsteroid hormone levels, improvements in immune function, and reduced systemic
inflammation and oxidative damage (Betoff et al., 2013). Most of these studies have
been conducted amongst breast cancer survivors, though at least one has been done in
each of colorectal, lung, prostate, and gastrointestinal cancer patients. While there is still
much research needed to understand how exercise may effect the progression of a
tumor, there is evidence building that the end result—mortality, from both the cancer
and all causes—can be significantly reduced through exercise.
2.4.3 Exercise Intensity, Cardiorespiratory Fitness, and Cancer Risk and
Survival
The main acute variables of exercise prescription are frequency, duration, mode,
volume and intensity (Pollock, Gaesser & Butcher, 1998). While volume generally
refers to the sets and repetitions used for a particular exercise, in a much broader sense,
it can encompass the duration and frequency equating to the total amount of exercise
performed (Fleck, 2004). Volume of training has received the most research attention
(Peterson et al., 2005). It is likely that there is an optimal volume of training achievable,
whereby further increases in training volume would not allow for further fitness
improvements, or may result in overtraining and fatigue (Gonzalez-Badillo, Gorostiaga,
Arellano & Izquierdo, 2005). Therefore, progressive manipulation of training intensity
is paramount for continual improvement without risk of detriment to physiological
performance (Peterson et al., 2005). Any of the acute training variables can be
28
manipulated in an attempt to trigger adaptation; however, intensity may have a crucial
effect on physiological and psychological changes in cancer survivors (Brown et al.,
2011; Ferrer et al., 2011; Hamer et al., 2009; Laukkanen et al., 2011). This section
reviews six specific studies, which examined not just total physical activity, but delved
specifically into the intensity of the exercise. The results of these studies indicate that
performing three hours or more of vigorous intensity (> 6 METs) exercise each week
may be the critical level of exercise that cancer survivors must attain to improve
survival and decrease risk of cancer reoccurrence.
Two epidemiological studies demonstrated how intensity of lifetime physical
activity, rather than volume, predicted the risk of developing prostate cancer
(Friedenreich et al., 2004; Giovannucci et al., 2005). Friedenreich et al. (2004)
retrospectively assessed the physical activity levels of Canadian prostate cancer
survivors and healthy male controls, matching for age and area of residence.
Giovannucci et al. (2005) used prospective data from the Health Professionals Followup Study to assess the association between physical activity and prostate cancer
incidence. Both studies gathered data on physical activity volume and intensity. They
performed hazard-ratio analyses to determine the cancer incidence risks associated with
different volumes and intensities of physical activity. Both concluded that only those
who participated in regular vigorous physical activity throughout their lifetime would
have a statistically significant lower risk—70% less—of developing cancer than
sedentary individuals. In contrast, performing moderate intensity physical activity did
not confer a statistically significant lower incidence risk. Both studies also concluded
that at least three hours per week of vigorous physical activity was needed to confer this
protective effect. Friedenreich et al. (2004) emphasised how the risk reduction of
developing prostate cancer was not significant for men who had completed the largest
29
volume of lifetime physical activity, when the intensity of that activity was not
accounted for.
Two studies examined physical activity levels prior to breast cancer diagnosis
and risk of all-cause mortality at five years post-diagnosis (Irwin et al., 2008; WestWright et al., 2009). These studies found that women meeting the physical activity
guidelines (PAG) before diagnosis had about a one-third lower risk of all-cause
mortality than women who had not met the PAG. Women who met the PAG in the year
prior to diagnosis had a 31% lower risk of death (Irwin et al., 2008), and those who
consistently met the PAG throughout their life had a 35% lower risk of death (WestWright et al., 2009). Combined, these studies demonstrated the protective effect prediagnosis physical activity has for women unfortunate enough to develop breast cancer
(Irwin et al., 2008; West-Wright et al., 2009).
The Health, Eating, Activity and Lifestyle (HEAL) study also examined postdiagnosis activity levels and changes in activity level from pre- to post-diagnosis for
their effects on mortality risk (Irwin et al., 2008). The results indicated that postdiagnosis physical activity levels had a greater effect on survival than did pre-diagnosis
physical activity levels, and that changes in physical activity levels from pre- to postdiagnosis were more important than the absolute level of activity during either period.
Further, breast cancer survivors who met the PAG in the first two years post-diagnosis
had a 67% lower likelihood of dying than sedentary women. More physical activity
conferred greater protection, with women performing at least 24 MET hours per week
having a 73% lower mortality risk. Women who increased their physical activity levels
after breast cancer diagnosis had a 45% reduction in mortality risk compared to women
who were always inactive. Surprisingly, women who maintained their level of physical
activity from before to two years after diagnosis (were active, but did not increase their
30
activity levels) had a 55% greater risk of death than women who were always inactive.
Most extraordinarily, though, was that women who decreased their physical activity
levels after diagnosis had almost a four times greater risk of death than perpetually
sedentary women. These results all highlight the importance of increasing physical
activity levels after cancer diagnosis, regardless of pre-diagnosis physical activity
levels.
A common limitation of the studies conducted by Irwin et al. (2008), WestWright et al. (2009) and Friedenreich et al. (2004) was that the studies were
retrospective, requiring participants to recall their physical activity levels. In the study
by Irwin et al. (2008), participants only had to recall the previous three years, whereas
in the West-Wright et al. (2009) and Friedenreich et al. (2004) studies, participants had
to recall an average of 40 years of physical activity. While the long-term recall
instruments used in these studies were validated tools, any recall study is limited in its
accuracy. The outcome of these studies suggested a dose–response between the level of
physical activity and cancer survival, and thus justified further exploration of the
relationship of high intensity exercise to cancer survival.
Two studies prospectively examined post-diagnosis physical activity levels in
cancer survivors and their all-cause mortality risk (Hamer et al., 2009; Laukkanen et al.,
2011). Both concluded that exercise intensity was much more influential on all-cause
mortality than exercise volume for cancer survivors. Hamer et al. (2009) analysed data
from a mixed group of male and female cancer survivors, who were, on average, almost
five years past cancer diagnosis. The data were drawn from Scottish Health Surveys
completed in 1995, 1998 and 2003, and were linked to the Scottish Cancer Registry in
order to determine cancer diagnosis and to track survival. The selected participants were
interviewed to determine how much physical activity they had performed in one month
31
in three categories: domestic activities, walking and sports. Physical activity was
assessed as frequency and duration of participation in the three types of activity each
week for the four weeks prior to the assessment.
A hazard-ratio analysis showed no associations between all-cause mortality and
domestic activity or walking, thereby suggesting that light to moderate physical activity
provided no survival benefits for cancer survivors. In contrast, participating in sport was
associated with a 53% reduction in risk of death. Hamer et al. (2009) concluded that the
intensity of the physical activity was more important in determining survival than the
duration or total volume of exercise in cancer survivors. After synthesising the
literature, the authors concluded that:
considered together, evidence from these studies suggest that current
recommendations for minimal levels of physical activity in cancer survivors (30
min of moderate intensity physical activity on five or more days per week) may
be insufficient for reducing the risk of all cause mortality in some cancer groups.
(Hamer et al., 2009, p. 229)
Instead, they recommended that cancer survivors should perform vigorous activity three
days per week for at least 20 minutes per session to confer a protective effect on their
longevity.
A recent study examined the relationship between physical activity intensity and
cancer mortality in men with various cancers (Laukkanen et al., 2011). Nurses
interviewed the men and recorded their responses to a 12-month leisure time physical
activity questionnaire to determine their minutes per week of physical activity and
intensity (average MET level) of physical activity. The mean sample age was 53,
intensity level was 4.5 MET and weekly volume of physical activity was 7.7 hours. The
survey revealed that 27% of the participants performed less than 30 minutes of leisure
32
time physical activity per day (3.5 hours per week). In addition to the survey, the men
completed a VO2peak test on a bicycle ergometer to provide an objective measure of
cardiorespiratory fitness. The cancer deaths were tracked through the Finnish National
Death Registry until December 2005. In total, 181 men died from cancer during the
study time, at an average of 16.7 years from the baseline evaluation. The majority of
deaths were from gastrointestinal or lung cancer, with 13.8% of the deaths due to
prostate cancer. Men whose exercise intensity exceeded a 5.2 MET level had a
significantly lower risk of cancer death than those whose exercise intensity was lower
than 3.7 MET (Laukkanen et al., 2011)—these levels represent the upper and lower
ends of moderate intensity (three to six MET) (Ainsworth et al., 2000). The intensity of
the physical activity was not related to cancer deaths when men performed less than 30
minutes of leisure time physical activity per day (Laukkanen et al., 2011). This indicates
that a minimum volume of 30 minutes of daily physical activity is required to provide
any survival benefit.
Laukkanen et al. (2011) calculated hazard ratios for men who performed a
minimum volume of 30 minutes of physical activity per day, comparing high, moderate
and light intensities. When adjusting for confounders such as age, smoking, body mass
index (BMI) and diet, men who performed moderate intensity physical activity (three to
six MET) had a 49% lower risk of death, and those who performed high intensity (> 6
MET) had a 69% lower mortality risk. Laukkanen et al. (2011) found no independent
relationship between volume of leisure time physical activity and risk of cancer death
when not accounting for intensity, which indicates that intensity of exercise, rather than
volume, was a more important factor for decreasing cancer death risk.
Finally, VO2peak correlated with cancer death risk, with an increase of one MET
(about 3.5 mL/kg/min) indicating a 12% reduction in death risk (Laukkanen et al.,
33
2011). When VO2peak and leisure time physical activity level were both used as factors
in a multivariable-adjusted model, the correlation between physical activity level and
death risk weakened, while the relationship between VO2peak and death risk remained
virtually unchanged. This result shows that objective cardiorespiratory fitness level
(VO2peak) is more important to cancer survival than the amount of physical activity
performed. This indicates that cancer survivors should focus on achieving a high level
of cardiorespiratory fitness, rather than achieving a target level of physical activity.
Unfortunately, Laukkanen et al. (2011) did not determine an optimal threshold VO2peak
for cancer survivors. One may perform a large volume of lower intensity exercise and
receive little benefit for VO2peak beyond initial adaptation (Pollock et al., 1998).
Higher intensities are required to create the progressive overload needed for further
adaptation (McNicol, O’Brien, Paton & Knez, 2009). Therefore, if there is an absolute
VO2peak that cancer survivors need to achieve, as the results of Laukkanen et al. (2011)
indicate, high intensity exercise will likely need to be performed.
One limitation of the Irwin et al. (2008) study was the failure to analyse the
intensity of physical activity separate from total MET hours per week. This study
showed that women who performed 24 MET hours per week only had a 6% lower
mortality risk than women performing only nine MET hours per week. It is possible that
the women who were exercising for 24 MET hours per week were performing only a
greater volume, and not higher intensity, of physical activity. This conclusion is based
on a comparison of results with other epidemiological studies (Friedenreich et al., 2004;
Giovannucci et al., 2005; Hamer et al., 2009; Laukkanen et al., 2011). The HEAL study
showed only a 6% improvement in survival by more than doubling total physical
activity, as measured in MET hours per week. In contrast, Laukkanen et al. (2011)
showed that doubling exercise intensity led to a 20% improvement in survival.
34
The combined results of these studies indicate that, while there is a dose
response between physical activity volume and survivorship, the rate of increasing
benefit is minimal above meeting the PAG (Irwin et al., 2008; Laukkanen et al., 2011).
There appears to be a large difference in survival between cancer survivors who are
sedentary and those participating in 150 minutes per week of moderate intensity
exercise. However, there is little survival difference between cancer survivors who
perform 150 minutes per week of moderate intensity exercise, compared to those
completing greater volumes of moderate intensity exercise. The key to incurring further
survival benefits may be for cancer survivors to exercise at a high intensity.
The results of the studies reviewed in this section support the hypothesis that
high intensity exercise has a strong association with improved survival rates for cancer
survivors. This aligns with other epidemiological research that links higher levels of
cardiovascular fitness to decreased mortality (Blair et al., 1996; Kodama et al., 2009).
Higher intensity exercise allows for greater levels of cardiovascular fitness and provides
other cardio-protective benefits that contribute to living longer (Swain & Franklin,
2006). Further, these results show that the intensity, rather than the volume, of physical
activity is the key factor for decreasing death risk. Finally, post-diagnosis physical
activity appears to have greater importance for survival than pre-diagnosis physical
activity.
2.5 Quality of Life of Cancer Survivors
Multiple dimensions are used to describe QOL. At a National Cancer Institute
Workshop in the United States (USA), QOL was defined through its dimensions as a
patient’s subjective feelings of physical, psychological, emotional and social function
(Nayfield, Ganz, Moinpour, Cella & Hailey, 1992). This definition aligns with other
published literature on QOL, both for cancer survivors and the general population (Cella
35
et al., 1993; Courneya et al., 2003a; Fallowfield, 2002; Felce & Perry, 1995; Ganz,
Schag & Cheng, 1990; Sloan et al., 2002). Physical functionality is the ability to
complete activities of daily living without a burden of stress or pain. Psychological
functionality is the ability to complete cognitive tasks, which anxiety and depression
can compromise. Social functionality is the ability to engage in intimate and casual
relationships, feel comfortable around others and feel accepted and understood by
people. Emotional wellbeing is a feeling of contentment and independence (Fallowfield,
2002; Nayfield et al., 1992; Sloan et al., 2002). Loss of physical function can create
psychological distress in cancer survivors, and may be the most important aspect of
QOL, both during and after cancer treatments (Courneya et al., 2003a). Impairment of
any one dimension can negatively affect all the other dimensions, and thus affect total
QOL (Ferrell et al., 1997).
Many cancer survivors perceive themselves as still having poor QOL even after
completing treatment (Van Weert et al., 2005). Although QOL improves post-treatment,
studies have shown that even one year post-treatment, many cancer survivors still report
QOL scores lower than the general population (Bowen et al., 2007; Lee et al., 2011a). A
multitude of factors have been identified as being significantly associated with QOL
scores in cancer survivors, including age, cancer type, comorbidities, marital status,
socioeconomic status, ethnicity, gender, employment status, education, income level,
treatment type and dosage, physical activity levels, social support and personal
resilience (Chen et al., 2009; Faul et al., 2011; Ganz et al., 2002; Ganz et al., 2003;
Ganz et al., 2004; Moyer, 1997; Sanda et al., 2008; Schover et al., 1995; Zebrack, Yi,
Petersen & Ganz, 2008). Of these, the factors that seem to most affect QOL are physical
activity levels, time post-treatment, age, treatment regime, and general physical health
and/or comorbidities.
36
Numerous studies have sought to establish a normal time course for the
restoration of QOL after cancer treatment, with little success. Predictions for cancer
survivors to regain pre-treatment QOL levels range from only 12 weeks with minimal
exercise participation (Park et al., 2012) to six months without any intervention (Lin,
Yu, Lin, Yang & Kao, 2012) to as long as eight to 10 years post-treatment (Ganz et al.,
2003; Zebrack et al., 2008). Ganz et al. (1992) noted that, after the initial decline, QOL
started to improve four months post-treatment, and by seven months had significantly
improved from the immediate post-treatment low, although QOL had not returned to
pre-treatment levels. Additionally, different aspects of QOL seem to act according to
different timelines. Many of the cancer-specific QOL issues—such as psychological
adjustment to the cancer and fears of reoccurrence or progression of the disease—seem
to resolve themselves in most people with the natural passage of time (Ganz et al., 2003;
King, Kenny, Shiell, Hall & Boyages, 2000; Moyer, 1997; Schover et al., 1995). In
contrast, more global QOL issues, such as general physical health, do not appear to be
time-dependent (Ganz et al., 2003; Moyer, 1997; Schover et al., 1995). In general, some
researchers accept one year as a sufficient period for cancer survivors to regain their
feelings of QOL (Ganz, Schag, Lee, Polinsky & Tan, 1992; Moyer, 1997; Schover et
al., 1995).
Typically, cancer survivors who are diagnosed at a younger age (< 50 years)
experience significantly worse QOL because their cancer may be more aggressive and
can interfere with their life to a greater extent, such as by disrupting their ability to have
or raise children (Harrison, Hayes & Newman, 2010; Schover et al., 1995; Zebrack et
al., 2008). Middle aged and older, but not elderly, cancer survivors (approximately 50 to
75 years old) seem to cope best due to having greater life experience, more general
coping strategies, and more time and leisure after retirement (Cimprich, Ronis &
37
Martinez-Ramos, 2002; Ganz et al., 2003; Schover et al., 1995; Zebrack et al., 2008).
Ganz et al. (2003) found that elderly cancer survivors (> 75 years old) experienced
worse QOL than those aged 65 to 74 years because they had less social support and
experienced age-related declines in physical functioning.
Treatment type and dosage have also been identified as major factors in
determining how much loss in QOL cancer survivors experience. These are most often
linked to QOL impairments that last for years beyond treatment completion (Ganz et al.,
2002; Ganz et al., 2004; Schover et al., 1995). Systemic treatments such as
chemotherapy, adjuvant hormone therapies such as Tamoxifen, and ADT have a more
negative influence on cancer survivors’ health and QOL than acute treatments such as
surgery (Ganz et al., 2002; Ganz et al., 2004; Schover et al., 1995).
A person’s general physical health and/or the presence of any comorbidity
before or after cancer diagnosis, especially obesity, have been linked to diminished
QOL (Sanda et al., 2008; Schover et al., 1995; Zebrack et al., 2008). Epidemiological
research has consistently shown that cancer and its treatments can lead to, or exacerbate,
conditions such as obesity, diabetes and CVD (Antonelli, Freedland et al., 2009;
Beehler et al., 2009; Courneya & Karvinen, 2007; Demark-Wahnefried et al., 1997b).
Jefford et al. (2008) developed a list of the six most frequent and intense needs of
cancer survivors, which are summarised in Table 1. The most important need of these
survivors was to return to a normal life, even if this was a new definition of ‘normal’
than before their diagnosis.
38
Table 1
Major Needs of Cancer Survivors
Rank
1.
2.
3.
4.
5.
6.
Need
Getting back into a routine and having a ‘normal’ life
Coping with fatigue and other side effects
Anxiety over discharge from the healthcare system
Fear about cancer recurrence and the future
Dealing with depression
Relating to others and reintegrating socially
Source: compiled from Jefford et al. (2008).
This information was collected from three focus groups comprising 22 cancer
patients. Fifteen of the patients were female, and seven of those had breast cancer. Of
the other patients, five had cancer of the gastrointestinal tract, three had lung cancer,
three had haematological cancer, and one each had been diagnosed with cancers of the
larynx, testis, ovary, and a sarcoma. While 41% of the subjects had completed treatment
within two years of participating in the study, and 77% within 10 years, no limit was
placed on time out from treatment. In addition to the patients, four other focus groups
sampled 20 health professionals. These included medical and radiation oncologists,
haematologists, nurses and allied health professionals. The facilitator asked all the
participants questions about the psychosocial and QOL issues of cancer survivorship.
The patients were asked to focus on how they felt both immediately after treatment and
one year later. The authors created an intensity rating system based on language usage,
which was detailed in their report. Jefford et al. (2008) identified these needs as being
the main factors contributing to QOL. These needs fit into the QOL dimensions of
physical, psychological and social wellbeing, and, if met, may improve a patient’s QOL.
The proposed program in the present study aimed to provide participants with a routine
social and physical activity designed to increase energy and physical function, while
giving them a forum to help cope with anxiety, fear and depression.
39
2.5.1 Quality of life specific to breast and prostate cancer survivors.
Although there are some needs common to all cancer patients, such as those
identified by Jefford et al. (2008), there are issues specific to each diagnosis that affect
QOL. Problems specific to breast cancer, identified as having serious negative effects
on QOL, include impaired shoulder function and range of motion (ROM),
lymphoedema and chemotherapy-induced neuropathy (Binkley et al., 2012). The
primary specific complications of prostate cancer that negatively affect QOL are erectile
dysfunction and urinary incontinence (Treiyer et al., 2011). While these physical
limitations of the male reproductive organs are specific to the gender, both populations
often experience negatively changed feelings of sexuality (Binkley et al., 2012; Ferrell
et al., 1997; Lintz et al., 2003).
While much work has been undertaken to address the above issues for breast
cancer survivors (Box, Reul-Hirche, Bullock-Saxton & Furnival, 2002a, 2002b;
Cassileth et al., 2011; Dimeo, Fetscher, Lange, Mertelsmann & Keul, 1997; Hammond
& Mayrovitz, 2010; Irdesel & Kahraman, 2007; Kilbreath et al., 2012), comparatively
little has been conducted regarding how exercise or other rehabilitation modalities may
improve sexual dysfunction and incontinence in prostate cancer survivors (Cormie et
al., 2013; Molton et al., 2008). Even two years post-treatment, sexual function may be
significantly worse than pre-treatment levels, which can negatively affect QOL (Sanda
et al., 2008). It is difficult to account for the difference in importance that individuals of
seemingly similar backgrounds place on the same factor. In context, one man may see
his sexual dysfunction as hugely detrimental to his QOL, while another may not be
disturbed. Additionally, it is even more difficult to compare QOL between two people
or groups of people who are dissimilar, such as breast and prostate cancer survivors.
These groups’ differing needs may create dissimilar responses to the same intervention
40
on QOL questionnaires. It is likely that breast cancer survivors may be able to improve
shoulder function through participation in exercise, which may lead to feelings of an
improved QOL. In contrast, prostate cancer survivors may have limited or no success
improving their erectile function through general exercise. This may explain why Ferrer
et al. (2011) found that exercise was more effective for improving QOL for women than
for men.
To meet the needs of breast and prostate cancer survivors, it may be optimal to
use both physical and psychological intervention components, as the multi-modal
approach addressed the various dimensions of QOL. The following sections will
examine how exercise and counselling have been used previously to improve cancer
survivors’ QOL, highlighting specifically the role exercise intensity might play.
2.5.2 Exercise and quality of life.
A well-designed exercise program can improve QOL in cancer survivors by
increasing physical function (Cho et al., 2006; Courneya et al., 2003a; Courneya,
Mackey & McKenzie, 2002; Hayes et al., 2009; Thorsen et al., 2008). Combined with
an increase in joint ROM created through functional exercises and flexibility training,
increased physical performance makes activities of daily living easier to accomplish and
less fatiguing (Brill, Macera, Davis, Blair & Gordon, 2000; McNeely et al., 2006).
Exercise programs have been shown to increase the following physical attributes in
cancer survivors: muscle strength and endurance, aerobic fitness, anti-inflammatory
interleukin-6 cytokines, resting lymphocyte count, bone mineral density, sleep quality
and flexibility (Antonelli, Freedland et al., 2009; Galvao et al., 2008; Tang, Liou & Lin,
2009; Thorsen et al., 2008; Waltman et al., 2010). Concurrently, exercise decreases the
physical symptoms of fatigue, adiposity, blood triglyceride levels, cachexia and risk of
CVD and other comorbidities (Antonelli, Freedland et al., 2009; Cho et al., 2006;
41
Galvao et al., 2009; Monga et al., 2007; Segal et al., 2009; Thorsen et al., 2008). In
addition to these physiological improvements, most of these interventions contributed to
increased scores on QOL questionnaires. Increasing cardiorespiratory fitness is the most
important exercise benefit for improving QOL (Courneya et al., 2009; Herrero et al.,
2006); however, improved body composition and strength also make significant
contributions (Silva Neto, Karnikowiski, Tavares & Lima, 2012). More specific to
breast and prostate cancer survivors, poor shoulder function and incontinence both
decrease QOL, but can be improved by exercise (Caban et al., 2006; Ganz et al., 1992;
Kuehn et al., 2000; Lin, Yang, Chia-Hsiang Lin, Yu & Chiang, 2011; McNeely et al.,
2010; Treiyer et al., 2011).
In addition to physical benefits, exercise has been directly linked to some
psychological benefits for cancer survivors. These include decreased emotional
discomfort, improved social wellbeing, reduction in feelings of depression and anxiety,
increased sense of control and hope, and a sense of belonging in a community (Cho et
al., 2006; Keays et al,. 2008; Losito, Murphy & Thomas, 2006; Monga et al., 2007;
Mustian et al., 2009). The best understood mechanism by which these improvements
occur is through an acute release of endorphins after a bout of exercise (McMurray,
Forsythe, Mar & Hardy, 1987; Yeung, 1996). Another important psychological benefit
of exercise for cancer patients is the sense that they are directly and actively
contributing to their own recovery (De Nijs, Ros & Grijpdonck, 2008; Knobf, Insogna,
DiPietro, Fennie & Thompson, 2008). According to De Nijs et al. (2008) and Knobf et
al. (2008), cancer survivors feel empowered when taking control of their health, and this
is a positive contribution towards the psychological dimension of QOL.
Exercise may also benefit the social dimension of QOL. Enrolling in a formal
exercise program can provide survivors with a regularly scheduled activity (Jefford et
42
al., 2008). In addition, when exercise is conducted in groups, the members socially
support each other (Cho et al., 2006; Courneya et al., 2003a; Kolden et al., 2002; Plow,
Mathiowetz & Lowe, 2009). These benefits address the first and third most important
needs identified by Jefford et al. (2008) (see Table 1)—to return to a normal routine and
to reduce anxiety after being discharged from the healthcare system.
2.5.2.1 Exercise intensity and quality of life.
The meta-analysis by Ferrer et al. (2011) provides the most current examination
of the effect of exercise on cancer survivors’ QOL by identifying the characteristics of
exercise interventions that most influence QOL changes. The authors examined 91
interventions that had collectively studied 3,629 cancer survivors. The characteristics
examined included number and length of sessions, theory-driven content, exercise
leader training and structure, and inclusion of exercise modes. Intensity of exercise, as
described by MET, was the most important factor for determining change in QOL.
Specifically, aerobic MET formed a quadratic relationship with QOL change, with
moderate intensity exercise (six MET) eliciting exponentially greater improvements
than low intensity exercise (four MET). In contrast, Burnham and Wilcox (2002) found
no difference between low (25 to 35% of heart rate [HR] reserve) and moderate (40 to
50% of HR reserve) intensity aerobic exercise on any outcome measure, including
QOL. One potential for the discrepancy is that the intervention studied by Burnham and
Wilcox (2002) only lasted 10 weeks. Ferrer et al. (2011) found that exercise intensity
had little effect on QOL change with short duration interventions (they assumed eight
weeks). They recommended that a short duration intervention compare high and
moderate intensity exercise to determine whether high intensity exercise could
significantly improve QOL in the short term, because low and moderate intensity
exercise did not.
43
In other chronic disease populations, such as people with CVD, diabetes and
osteopenia, higher intensity exercise has been shown to help patients manage or reverse
symptoms of these diseases more successfully than has lower intensity exercise
(Colberg et al., 2010; Kohrt, Bloomfield, Little, Nelson & Yingling, 2004; Rognmo,
Hetland, Helgerud, Hoff & Slordahl, 2004; Wisloff et al., 2007). Additionally, high
intensity exercise provided greater QOL improvements than moderate intensity exercise
among CVD patients (Wisloff et al., 2007). Further research is warranted to investigate
whether high intensity exercise provides any greater improvements in QOL for cancer
survivors than does lower intensity exercise.
In their meta-analysis, Ferrer et al. (2011) concluded that changes in QOL from
low intensity exercise interventions, which constituted the majority of the studies they
examined, may not have been attributable to physiological changes, but rather to
external factors, such as social support derived from trainer interaction. Hansen et al.
(2011) also highlighted other contextual confounders, such as the personality of the
exercise physiologist delivering the intervention. Ferrer et al. (2011) called for a single
study to compare exercise intensities in cancer survivors in order to verify their
conclusions. When attempting to ascertain whether exercise intensity modulates QOL, it
is important to account for external factors, other than exercise intensity’s effect on
QOL, such as depression or social support from a structured program (Ferrell et al.,
1997; Ferrer et al., 2011).
2.5.2.2 Exercise and cancer-related fatigue.
Cancer-related fatigue is a debilitating side effect that negatively affects QOL
and is experienced by 70% or more of cancer survivors during treatment (Arnold &
Taylor, 2011; Garabeli Cavalli Kluthcovsky et al., 2012; Stone, Richards, A’Hern &
Hardy, 2001). This almost universal fatigue has been widely accepted, but has recently
44
come under scrutiny as being largely over-reported (Cho, Dodd, Cooper & Miaskowski,
2012; Garabeli Cavalli Kluthcovsky et al., 2012). During treatment, it is possible and
likely that most or all cancer survivors will feel fatigued; however, only approximately
one-third of cancer survivors will develop cancer-derived chronic fatigue (Garabeli
Cavalli Kluthcovsky et al., 2012). Cancer-derived chronic fatigue is debilitating because
it creates a vicious cycle between increasing fatigue levels and decreasing physiological
function and physical activity (Neil et al., 2013; Battaglini, Dennehy, Groff, Kirk &
Anton, 2006). Low to moderate intensity exercise may successfully improve cancerderived chronic fatigue and break the debilitating fatigue cycle (Cantarero-Villanueva et
al. 2012; Dimeo, Schwartz, Wesel, Voigt & Thiel, 2008; Keogh & MacLeod, 2012;
Monga et al., 2007). However, it is unknown if high intensity exercise would reduce or
exacerbate fatigue levels.
An additional factor to consider is whether fatigue itself may be a barrier to
participating in high intensity exercise. Conversely, high intensity exercise may cause
fatigue and then discourage cancer survivors from continuing to exercise (Blaney et al.,
2010). Fatigue was a secondary outcome in the present study, but was included to gauge
whether high intensity exercise was fatiguing for breast and prostate cancer survivors.
Additionally, if QOL decreased in the high intensity exercise group, a concurrent
increase in fatigue may have helped explain that result.
2.5.3 Counselling and quality of life.
While exercise programs may achieve measurable improvements in some
psychological parameters, not all the mental and emotional wellbeing needs of cancer
survivors can be addressed through exercise alone. Another effective intervention for
cancer survivors involves psychological counselling programs with qualified
professionals. For the purposes of this literature review, counselling is defined as any
45
psychological, psychosocial or educational intervention (Tacon & McComb, 2009).
Counselling techniques used in cancer survivorship interventions have included
individual or group discussions; relaxation, mindfulness, awareness, breathing and HR
coherence techniques; and cognitive or behavioural modification sessions (Berglund,
Bolund, Gustavsson & Sjödén, 1993; Tacon & McComb, 2009).
Counselling is useful in addressing the majority of psychological, emotional and
social needs of cancer survivors. Major problems that fall into these domains include
stress, anxiety, depression, negative feelings about sexuality, loss of hope, social
isolation and fatigue (Berglund et al., 1993; Blake-Mortimer et al., 1999; Bordeleau et
al., 2003; Cain, Kohorn, Quinlan, Latimer & Schwartz, 1986; Courneya et al., 2003a;
Jacobsen, Donovan, Vadarampil & Small, 2007; Kalaitzi et al., 2007; Maeda, Kurihara,
Morishima & Munakata, 2008; Meyer & Mark, 1995; Spiegel et al., 2007). Stress
arising from being diagnosed with and treating a chronic disease may create a risk for
impaired immune, cardiovascular and endocrine functions (Tacon & McComb, 2009).
Thus, stress management should be an integral part of a complete treatment program
(Tacon & McComb, 2009).
Counselling interventions may also improve emotional adjustment, functional
adjustment and the ability to cope with symptoms (Meyer & Mark, 1995). It is
important that counselling—or any intervention model—be specific to a population in
order for it to be effective (Berglund et al., 1993). Group counselling is considered the
most effective because it provides opportunities for social support and comparison that
individual counselling does not offer (Breitbart, 2002; Courneya et al., 2003a). Social
support is very important because feelings of social isolation have been linked to a
higher mortality rate. Social support helps decrease the effects of many of the symptoms
of cancer treatment, including fatigue (Blake-Mortimer et al., 1999).
46
Breast cancer treatments can alter the physical appearance of a woman
dramatically. Mastectomy especially disrupts body image and sexuality in women.
These problems have been linked to worsening anxiety, depression and decreased QOL
in breast cancer survivors (Brady et al., 1997; Kalaitzi et al., 2007). For example, in the
Functional Assessment of Cancer Therapy-Breast (FACT-B) questionnaire for QOL
(Brady et al., 1997), the investigated elements include ‘I am self-conscious about the
way I dress’, ‘I feel sexually attractive’, ‘I am bothered about my hair loss’, ‘I am
bothered by a change in weight’ and ‘I am able to feel like a woman’. Likewise, in men,
the onset of sexual dysfunction after treatment for prostate cancer may disrupt their selfimage and sexual identity (Couper et al., 2006; Lintz et al., 2003; Treiyer et al., 2011).
Counselling can help patients address these issues by providing them with support, a
forum for discussion, and professional feedback and guidance.
The characteristics of a successful group counselling intervention identified by
Blake-Mortimer et al. (1999) include encouraging patients to maintain their regular
activities, teaching patients stress management and relaxation techniques, creating a
social network, allowing for the full expression of emotion while discouraging
emotional suppression and avoidance, and encouraging and helping patients
communicate with their families and healthcare practitioners. According to Bordeleau et
al. (2003), Cain et al. (1986) and Spiegel et al. (2007), the themes that should be
discussed during counselling sessions include:

learning about the disease

causes of the disease

treatment of the disease

the effect of treatment on body image and sexuality

relaxation and coping techniques
47

beneficial lifestyle changes

relationships with peers, family members and caregivers

prioritising and setting new goals for life with and after cancer.
2.5.4 Combined exercise and counselling interventions and quality of life.
Combining exercise and counselling may provide a holistic rehabilitation
intervention for breast and prostate cancer survivors. Currently, few studies have
assessed a combined exercise and psychological intervention for cancer survivors. The
multimodal studies that have been conducted have been limited in the scope of one or
more factors, including intervention delivery, sample size and/or length of trial
(Berglund et al., 1993; Block et al., 2009; Cho et al., 2006; Courneya et al., 2003a;
Culos-Reed et al., 2007; Naumann et al., 2012a; Naumann et al., 2012b; Rabin, Pinto,
Dunsiger, Nash & Trask, 2009; Van Weert et al., 2005). There is also a lack of
consistency in the psychological interventions delivered, such as individual
psychotherapy, group psycho-education, cognitive-behavioural counselling or group
thematic counselling.
Despite these limitations, a recent study found evidence that combining exercise
with psychological counselling creates additive benefits for breast cancer survivors’
QOL (Naumann et al., 2012a). In this study, the authors recruited 43 breast cancer
survivors within 18 months of treatment completion, and randomised them to
psychological counselling only, exercise only, combined exercise and psychological
counselling, and a usual care control group. The combined exercise and counselling
group improved their QOL score, as measured by the FACT-B, by more than double the
sum of the improvement of the exercise only and counselling only groups. The authors
concluded that an interaction effect of combining the two modalities existed, whereby
48
the two interventions added value to each other for the benefit they could bestow upon
breast cancer survivors’ QOL.
The third component of the present study’s intervention design was that the
exercise and counselling were delivered to groups of breast and prostate cancer
survivors, with the intention of providing a more comprehensive rehabilitation program.
As previously discussed, exercising as a group could provide a social construct to meet
the needs of cancer survivors (Jefford et al., 2008). Participating in counselling as a
group is considered to yield the greatest benefits because it provides members with
opportunities for peer support, comparison and modelling (Courneya et al., 2003a).
Naumann et al. (2012a), after their initial success combining exercise and counselling,
examined whether a multimodal intervention could successfully be delivered in a group
setting (Naumann et al., 2012b). The aim was to deliver the intervention more
efficiently without losing any effectiveness of the outcomes (Naumann et al., 2012b).
The study compared 12 breast cancer survivors who participated in individual exercise
and individual counselling to 14 women who participated in group exercise and SGP. It
found no statistically significant difference in increases of QOL between the
intervention programs. Importantly, both groups exceeded the clinically minimal
important change of seven to eight points on their overall QOL score (McNeely et al.,
2006).
Together, these studies show that exercise and counselling are a powerful
rehabilitation combination for breast cancer survivors in both one-on-one and group
delivery. However, it was unclear whether these same benefits could also be realised in
participants with other forms of cancer, such as prostate cancer. Men typically do not
seek out psychological services, even after a cancer diagnosis (Boudioni et al., 2001;
Carmack Taylor et al., 2006; Eakin & Strycker, 2001; Kaplan, 2008; Krizek et al., 1999;
49
Nekolaichuk et al., 2011; Petersson et al., 2000; Plass & Koch, 2001; Sherman et al.,
2007; Steginga et al., 2008). Therefore, the pilot study for the present research focused
on the feasibility of delivering a group exercise and counselling intervention to prostate
cancer survivors. The results of the pilot study are presented in Chapter 3.
2.6 Current Exercise Guidelines for Cancer Survivors
The recent ACSM exercise guidelines for cancer survivors is the most
comprehensive publication currently written on the subject, with contributors from
major research groups across the world (Schmitz et al., 2010). The guidelines for breast
and prostate cancer are summarised as follows:

For breast and prostate cancer, the main goals of an exercise prescription
should be to improve cardiovascular capacity, strength and flexibility.
Improvements in these main components of fitness should help improve
secondary outcomes, such as QOL and body composition.

Breast cancer survivors presenting with shoulder impairment or
lymphoedema should have medical clearance before exercising, and exercise
should cease if symptoms present or worsen.

Breast and prostate cancer survivors undergoing hormone therapy may be at
risk of fracture from drug-induced or age-onset osteoporosis.

Prostate survivors who have undergone radical prostatectomy require pelvic
floor exercises.

If a break is taken in a normal exercise routine, ‘back off the level of
resistance by 2 weeks worth for every week of no exercise’ (Schmitz et al.,
2010, p. 1414).
In terms of acute variables of exercise prescription, the ACSM (Schmitz et al., 2010)
only stated that ‘Recommendations are the same as age-appropriate PAG for
50
Americans’ (p. 1414). Throughout this thesis, the American PAG will be referred to as
the PAG because of the direct reference by Schmitz et al. (2010) and others.
Additionally, the American PAG are more specific than the Australian National
Physical Activity Guidelines, which state “Put together at least 30 minutes of moderateintensity physical activity on most, preferably all, days” (Australian Government
Department of Health and Aging, 2013). In summary, the PAG recommend performing
moderate intensity exercise, such as brisk walking or leisurely bicycling (Ainsworth et
al., 2000), for 50 minutes per day on three days per week (Physical Activity Guidelines
Advisory Committee, 2008). In comparison to research discussed in the next section,
the PAG equate to performing approximately nine MET hours per week (Irwin et al.,
2008; Physical Activity Guidelines Advisory Committee, 2008). The ACSM
recommendations (Schmitz et al., 2010) and PAG (Physical Activity Guidelines
Advisory Committee, 2008) address general goals, frequency and duration of exercise,
but do not give explicit guidelines on many of the acute variables necessary for creating
an exercise prescription. The PAG do not make any more specific recommendations for
older and at-risk adults, except for suggesting that they attempt to follow the guidelines
for healthy adults to the best of their ability. Individual research groups, many of whom
had representatives at the ACSM Roundtable discussion (Schmitz et al., 2010),
provided more detailed guidelines, which are summarised in Table 2.
51
Table 2
Summary of Exercise Guidelines for Cancer Survivors
Mode
Aerobic
(Courneya et al., 2002;
Courneya & Mackey,
2001; Mustian et al., 2009;
Newton & Galvao, 2008).
Volume
Build from 10–90 minutes of work.
Intervals of 3–10 minutes,
interspersed with rest, that add up to
30 minutes may also be effective at
improving QOL and side effects.
Intensity
Cancer survivors should
perform aerobic exercise at
55–75% of maximum HR, or
at an intensity corresponding to
11–14 on the rating of
perceived exertion (RPE)
scale.
Resistance
(Courneya et al., 2002;
Courneya & Mackey,
2001; Galvao et al., 2007;
Mustian et al., 2009;
Newton & Galvao, 2008).
Resistance exercises should be
undertaken 3 days per week, with
volume ranging from 1–4 sets of 6–
15 repetitions. Performing resistance
training with these variables takes
10–30 minutes.
50–90% 1RM.
Flexibility
(ACSM, 2006; Newton &
Galvao, 2008).
Patients should perform flexibility
training 2–3 days per week, holding
stretches for 15–30 seconds, and
performing stretches 2–4 to four
times. Stretching takes up 5–10
minutes of a workout.
Not applicable.
While these guidelines are more specific than the ACSM Roundtable guidelines,
they still provide a wide range of intensities for survivors to perform their exercise,
especially for resistance exercise. There is a need for resistance training intensities to be
better defined and compared to specify a dose–response relationship on all components
of fitness, health and QOL (Ferrer et al., 2011; Schmitz et al., 2010; Van Waart, Stuiver,
Harten, Sonke & Aaronson, 2010). Additionally, considering the various needs of each
cancer population, different recommendations may be needed for each group, furthering
the segmentation started by the ACSM (Schmitz et al., 2010). The guidelines presented
in Table 2 do not recommend high intensity aerobic exercise—they recommend that
cancer survivors perform only low to moderate intensity exercise (Courneya et al.,
2002; Courneya & Mackey, 2001; Mustian et al., 2009; Newton & Galvao, 2008). As
discussed in a later section about the potential safety of high intensity exercise in cancer
survivors, this is due to an appropriately conservative starting point for exercise
52
prescription recommendations (Jones et al., 2010b). As more research demonstrates the
safety and efficacy of high intensity exercise in cancer survivors, the guidelines will
likely evolve, as they have for diabetes and osteoporosis (Colberg et al., 2010; Kohrt et
al., 2004). Paving the way are retrospective and observational epidemiological studies
that have shown that high intensity exercise has significantly greater benefits for cancer
survival than does lower intensity exercise (Friedenreich et al., 2004; Giovannucci et al.,
2005; Hamer et al., 2009; Laukkanen et al., 2011). These studies’ findings will be
reviewed and discussed in the following section, which will indicate that higher
intensity exercise has a possible place in rehabilitation programs.
2.7 High Intensity Exercise and Cancer Survivors
Exercise can be a potent stressor to the body (Seyle, 1936; Wittert, Livesey,
Espiner & Donald, 1996); however, the exact stress effects of exercise in cancer
populations are still being elucidated (Jones et al., 2010b). It is possible that there is a
threshold of exercise intensity and volume, beyond which a person—whether healthy or
with a chronic disease—could harm themselves. If an exercise protocol was known to
be unsafe, it would be unethical to subject participants to this. Some limited information
is emerging regarding the safety of high intensity exercise for cancer and CVD
survivors (Adamsen et al., 2009; De Backer et al., 2008; Nilsson, Westheim & Risberg,
2008; Quist et al., 2006; Rognmo et al., 2004; Wisloff et al., 2007).
2.7.1 Efficacy and risks of high intensity exercise in cancer survivors.
Emerging research suggests that high intensity exercise is effective for
improving VO2peak, strength and QOL in cancer survivors, and does not put most
cancer survivors at risk of injury or compromised immune function (Adamsen et al.,
2009; De Backer et al., 2008; Fairey et al., 2005; Galvao et al., 2008; Quist et al., 2006).
However, it seems that high intensity exercise does pose a risk to some cancer
53
populations—most notably haematological cancer and brain tumour survivors
(Adamsen et al., 2009; Quist et al., 2006). This information was important to ensure the
present study had the greatest chance of providing the basic physiological and QOL
changes needed to answer the research questions, and to ensure any potential subjects
were not put under undue risk by participating in this study.
Three studies examined the physiological response of mixed groups of cancer
survivors to high intensity aerobic and resistance training (Adamsen et al., 2009; De
Backer et al., 2008; Quist et al., 2006). Two of the studies were conducted in the same
laboratory and recruited groups of mixed cancer survivors undergoing chemotherapy
(Adamsen et al., 2009; Quist et al., 2006). The other study also recruited a mixed group
of cancer survivors, but these patients had completed chemotherapy (De Backer et al.,
2008). The interventions used in these studies ranged from six to 18 weeks, with
exercise sessions held one to three days per week. High intensity aerobic exercise was
prescribed as 65% of maximal short exercise capacity (the maximum workload
achieved during the VO2peak test) (De Backer et al., 2008), 75 to 85% VO2max (Quist
et al., 2006), or 85 to 95% HRmax (Adamsen et al., 2009). The duration of aerobic
exercise ranged from eight to 15 minutes of stationary cycling. High intensity resistance
exercise was prescribed as 65 to 80%, 85 to 100%, or 70 to 80% of 1RM (Adamsen et
al., 2009; De Backer et al., 2008; Quist et al., 2006). The volumes of resistance training
ranged from three to six exercises, using a range from two sets of 10 repetitions to three
sets of eight repetitions.
These studies had modest adherence and compliance rates of 70 to 77%. This
indicates that high intensity exercise may not be physiologically possible or feasible for
all cancer survivors to participate. More importantly, high intensity exercise may not be
safe for haematological or brain cancer survivors, as indicated by a series of adverse
54
events in participants with these forms of cancer (Adamsen et al., 2009; Quist et al.,
2006). One positive outcome was that none of the breast cancer survivors with
lymphoedema experienced an exacerbation of their swelling (Adamsen et al., 2009).
Despite these drawbacks, these studies did show that high intensity exercise was
effective at improving cardiorespiratory fitness and strength among the participants
(Adamsen et al., 2009; De Backer et al., 2008; Quist et al., 2006). One excellent result
of these studies was that they provided large physiological improvements in a short
time. The intervention examined by Quist et al. (2006) only lasted six weeks, and
participants improved their VO2peak by 14.5%. These studies indicate a greater need to
examine the safety, feasibility and efficacy of high intensity exercise, but provide a
promising start to its use for cancer survivors.
One of the most important aspects of these studies was that the volume of
aerobic exercise was low, while the intensity was high, and all participants showed a
greater than 10% improvement in VO2peak (Adamsen et al., 2009; De Backer et al.,
2008; Quist et al., 2006). While the two Copenhagen studies (Adamsen et al., 2009,
Quist et al., 2006) elicited similar leg strength and VO2peak improvements in
comparison to the study by De Backer et al. (2008), they exhibited some of the risks
associated with high intensity training in cancer survivors. One possible explanation for
the adverse events is that the participants in the Quist et al. (2006) and Adamsen et al.
(2009) studies were currently undergoing chemotherapy, while those in the De Backer
et al. (2008) study had completed chemotherapy. It is possible that the participants
undergoing chemotherapy were both immunocompromised and experiencing systemic
toxicity (Dempsey, 2008; Finn, 2012). Indeed, among the haematological cancer
survivors, immune markers such as B thrombocytes and leucocytes were monitored, and
patients were prohibited from exercising if they did not meet the threshold level
55
requirements (Adamsen et al., 2009). Overall, these studies indicate that cancer
survivors can successfully adapt to higher intensity exercise, although safety is still an
issue that needs further investigation.
2.7.2 Exercise intensity and immune function in cancer survivors.
Exercise programs for deconditioned individuals should progress from lower to
higher intensities (Baker, Wilson & Carlyon, 1994). This progression decreases the risk
of injury and increases the body’s ability to continue to positively adapt to harder
exercise. The results of a study by Fairey et al. (2005) supported that proper progression
was also important for maintaining immune function in cancer survivors. In their study,
53 post-treatment breast cancer survivors were randomised to an aerobic exercise group
(n = 25) or a control group (n = 28) (Fairey et al., 2005). The aerobic exercise group
cycled at 70 to 75% VO2peak (moderate intensity) for three days per week for 15
weeks. Before each workout, the participants warmed up by cycling for five minutes at
50% VO2peak. In weeks one to three, they cycled for 15 minutes at this intensity; then,
every three weeks, they added five minutes to the cycling time. This methodical
increase in time represented a systematic overload, which is the key to appropriate
exercise progression (Baker et al., 1994).
The results of the Fairey et al. (2005) study indicated that the exercise program
did not compromise the breast cancer survivors’ immune function, but actually
improved several markers, including natural killer cell cytotoxic activity and
unstimulated [3H]thymidine uptake by peripheral blood lymphocytes. At the end of the
study, Fairey et al. (2005) concluded that progressive moderate aerobic exercise training
improved immune function in the breast cancer survivors. This was one of the first
studies to demonstrate that exercise does not suppress the immune systems of breast
cancer survivors—a population of women whose immune systems have already been
56
compromised by treatment. It is important to note that the exercise program employed
by Fairey et al. (2005) started the cardiovascular training at a moderate intensity and
gradually progressed towards a higher intensity. In contrast, the aerobic exercise portion
of the intervention used by Adamsen et al. (2009) started at a high intensity. It is
possible that the lack of progression from moderate intensity, demonstrated as being so
important by Fairey et al. (2005), contributed to the adverse events reported by
Adamsen et al. (2009).
High intensity exercise has been shown to acutely lower immune system
function, thereby exposing people to risk of disease and infection (Koch, 2010; Walsh et
al., 2011). Galvao et al. (2008) examined immune response to resistance training in 10
prostate cancer survivors who were undergoing ADT. The exercise program lasted 20
weeks, and the participants exercised two days per week. The exercise program was
periodised into two 10-week phases that systematically progressed the patients from
moderate to high intensity. They found no significant effect of 20 weeks of resistance
training on the systemic concentrations of interleukin-6, interleukin-1ra and tumour
necrosis factor-alpha, thus indicating that prostate cancer survivors currently undergoing
ADT have a similar immune response to healthy adults when completing resistance
training, and are at no increased risk by undertaking resistance training when the
program is properly progressed. Further, attention to exercise technique, especially for
resistance training, is paramount for both successful adaptation and preventing injury.
The combined results of these studies (Adamsen et al., 2009; De Backer et al.,
2008; Fairey et al., 2005; Galvao et al., 2008; Quist et al., 2006) indicated that, as long
as an exercise program is systematically overloaded and properly supervised,
progressing many cancer survivors to high intensity should pose little increased risk to
their health, including to their immune system function. However, these studies do
57
highlight that the safety of exercise, especially high intensity exercise, has not been
thoroughly demonstrated in all cancer survivor populations. The mixed results of these
studies warrant further investigation.
2.7.3 High compared to low to moderate intensity exercise.
To date, the only research comparing higher and lower intensity exercise in
cancer survivors has published the protocol design, but not the results (Jones et al.,
2010a). However, several CVD populations have successfully completed high intensity
exercise programs (Nilsson et al., 2008; Rognmo et al., 2004; Wisloff et al., 2007). Two
studies compared high intensity to low intensity exercise for differences in VO2peak
response (Rognmo et al., 2004; Wisloff et al., 2007). The results supported the safety of
high intensity exercise in an at-risk population, as evidenced by no adverse coronary
events (Nilsson et al., 2008; Rognmo et al., 2004; Wisloff et al., 2007).
The purpose of the studies by Rognmo et al. (2004) and Wisloff et al. (2007)
was to compare the effectiveness of high intensity exercise against moderate intensity
exercise in different CVD populations. In both studies, the participants were randomised
to either high intensity interval training or moderate intensity continuous training, both
performed on treadmills. Participants in the Rognmo et al. (2004) study had a
compliance rate of 70%, and there were no adverse events during the study. While both
groups significantly improved their VO2peak, the high intensity group improved
17.9%—twice as much as the 7.9% improvement of the moderate intensity group. As
the workloads were matched between the groups, this study provided direct evidence
that the intensity of exercise—and not the total amount of work—is the most important
for improving VO2peak.
In the study by Wisloff et al. (2007), the training loads were matched for total
caloric expenditure. The patients in both groups exhibited significant improvements in
58
cardiovascular endurance, with the high intensity interval training and moderate
continuous training groups improving their VO2peak by 46% and 14%, respectively.
These studies (Rognmo et al., 2004; Wisloff et al., 2007) demonstrate that high-risk
CVD patients can safely exercise at high intensities, exhibit a dose–response
relationship between aerobic intensity and cardiovascular capacity, and have
significantly more benefit to gain for VO2peak from working at higher intensities rather
than only moderate intensities. At present, it is unclear whether high intensity exercise
is safe for all cancer survivors, or whether they exhibit a similar relationship between
exercise intensity and VO2peak gains. Indeed, some studies have indicated that high
intensity exercise may not be suitable for haematological cancer or brain tumor
survivors (Adamsen et al., 2009, Quist et al., 2006). It is also unclear whether there is a
relationship between exercise intensity and other outcomes, such as QOL. Such
information would give cancer survivors and exercise physiologists an appropriate
target of fitness to achieve in order to facilitate optimal gains in health, fitness and
QOL.
During the last 50 years, the attitudes of exercise physiologists have changed
regarding what exercise is appropriate and warranted in chronic disease populations.
The studies reported above (Nilsson et al., 2008; Rognmo et al., 2004; Wisloff et al.,
2007) evidenced that exercise physiologists accept high intensity exercise as safe and
able to provide greater benefit to CVD populations than does low intensity exercise.
Currently in the United Kingdom (UK), only light to moderate intensity aerobic
exercise is offered for cardiac rehabilitation exercise programs (Gillison, Skevington,
Sato, Standage & Evangelidou, 2009; Probert et al., 2009). As more evidence accrues
regarding the safety and efficacy of high intensity exercise in cardiac rehabilitation,
these standards may soon change. In diabetes and osteoporosis, this transformation has
59
already occurred. For example, the ACSM position stand on exercise and type 2
diabetes recommends high intensity aerobic and resistance exercise for optimal
management of blood sugar levels and to decrease diabetic complications (Colberg et
al., 2010). This high intensity exercise recommendation was not the case 10 years ago
(Kelley & Goodpaster, 1999; Sigal, Kenny, Wasserman & Castaneda-Sceppa, 2004).
Likewise, the ACSM now promotes high load resistance training to prevent or
manage osteoporosis, and state that just walking does not create enough impact loads to
improve bone health (Kohrt et al., 2004). It is understandable and appropriate for
exercise interventions to start conservatively and at a low intensity for high-risk
populations (Jones et al., 2010b), but then build up over time. The mounting evidence
across CVD, diabetes, osteoporosis and now cancer shows that high intensity exercise
may be both safe and appropriate for individuals who can tolerate it. Like the reviewed
CVD studies (Nilsson et al., 2008; Rognmo et al., 2004; Wisloff et al., 2007), the
present study will be one of the first to determine whether high intensity exercise is
more beneficial for breast and prostate cancer survivors than lower intensity exercise for
improving QOL, physiological function, fatigue and exercise motivation.
Concurrently, a research group at Duke University led by Dr Lee Jones is
investigating if high intensity aerobic exercise provides greater benefits than lower
intensity exercise for breast cancer survivors (Jones et al., 2010a). In their trial design
publication, Jones et al. (2010a) outlined a study design similar to the CVD studies
reviewed above (Rognmo et al., 2004; Wisloff et al., 2007), incorporating high intensity
aerobic exercise performed on a treadmill. Jones et al.’s (2010a) intention is to compare
moderate intensity aerobic exercise (60 to 70% VO2peak) with moderate to high
intensity aerobic exercise (60 to 100% VO2peak). At the time of writing, they had not
60
published their outcomes. These outcomes will provide good evidence of the
cardiorespiratory benefits of high intensity exercise for breast cancer survivors.
2.8 Exercise Motivation and Adherence in Cancer Survivors
Unless exercise behaviour is maintained, any fitness improvements made
through participation in an exercise intervention will be lost (Costill et al., 1979;
Fatouros et al., 2005). There is mixed evidence regarding whether or not cancer
survivors will maintain their physical activity levels beyond an intervention (Courneya
et al., 2007a; Daley et al., 2007; Mutrie et al., 2012; Rogers et al., 2009). Few studies
have followed cancer survivors after participating in an exercise intervention to
determine if they maintain their exercise behaviour or fitness levels (Courneya et al.,
2007a; Daley et al., 2007; De Backer et al., 2008; Milne, Wallman, Gordon &
Courneya, 2008a; Mutrie et al., 2012; Rogers et al., 2009; Thorsen, Dahl, Skovlund,
Hornslien & Fossa, 2007). Of these studies, only four monitored physical activity levels
at follow up (Courneya et al., 2007a; Daley et al., 2007; Mutrie et al., 2012; Rogers et
al., 2009).
Daley et al. (2007) reported that the intervention participants did not maintain
their physical activity levels, and subsequently also did not maintain their QOL or
fatigue, at the six-month follow up. Rogers et al. (2009) reported that the intervention
participants had maintained physical activity levels, fitness and QOL three months after
intervention completion. Courneya et al. (2007a) reported that 42% of the participants
were not meeting either the resistance or aerobic exercise guidelines at the six-month
follow up. In one of the longest follow-up studies conducted in exercise oncology,
Mutrie et al. (2012) reported that cancer survivors maintained their physical activity
levels for five years, reporting 648 weekly minutes of moderate or vigorous leisure time
61
physical activity. They did not report how many of the survivors who participated in
their intervention decreased their physical activity levels over time.
The mixed success of interventions at promoting long-term physical activity
adoption in cancer survivors shows that further research is still needed to determine how
to motivate cancer survivors to maintain their exercise (Courneya et al., 2007a; Daley et
al., 2007; Mutrie et al., 2012; Rogers et al., 2009). One important technique for exercise
physiologists to employ is to ground their exercise interventions in behavioural theory
(Courneya et al., 2009; Ferrer et al., 2011; Hutchison, Breckon & Johnston, 2009;
Rogers et al., 2008; Vallance et al., 2010). There are a variety of theories, which
describe behavior change and adoption, that have been employed in exercise oncology
research. A summary of these theories and their major tenets can be seen in Table 3.
These behavioural theories were developed for the general population, but have been
employed to help cancer survivors increase and maintain their PA levels. Some of the
common themes amongst these theories are the need to form goals and execute a plan to
meet those goals and the importance of self-efficacy towards adopting and maintaining
physical activity.
A summary of interventions for breast and/or prostate cancer survivors, which
have explicitly employed one or more of these behavioural theories, can be seen in
Table 4. Of the 11 reviewed studies (some of which published preliminary and follow
up results in separate papers), seven were conducted exclusively with breast cancer
survivors, two were exclusively for prostate cancer survivors, and two had a mix of
cancer survivors. Two studies used a combination of Social Cognitive Theory and the
TTM. Three studies exclusively employed the Social Cognitive Theory, two used the
TTM, two were grounded in the Theory of Planned Behaviour, and one study each were
based on Cognitive Behavioural Therapy and Mindfulness Based Stress Reduction. Of
62
studies that compared increases in PA levels of an intervention group to a control group,
eight out of ten reported a significantly greater increase in PA due to the intervention.
The two studies that reported no difference employed Cognitive Behavioural Therapy
(Mefferd et al., 2007) and the Theory of Planned Behavior (Vallance et al., 2007;
Vallance et al., 2008). It is apparent that no one theory is more effective for improving
physical activity levels of cancer survivors; however, a review of the studies included in
Table 4 indicated that grounding an exercising intervention in a behavioural theory will
significantly help cancer survivors engage in and maintain a physical activity routine.
Table 3
Summary of Exercise Behaviour Theories
Theory Name
Cognitive Behavioral
Theory
(Compas, Haaga, Keefe,
Leitenberg, & Williams,
1998; Tatrow &
Montgomery, 2006)
Summary of Tenets
As an intervention, this theory employs the conscious examination of
thoughts, feelings, and behaviours by both the patient and the counsellor.
Together, they work as a team to come up with a plan to correct
maladaptive thoughts, feelings, and behaviours to align them with the
patient’s goals.
Mindfulness Based Stress
Reduction
(Baer, 2003; Kabat-Zinn,
1994; Kabat-Zinn, 2003)
Mindfulness is the conscious and purposeful awareness of the present
moment, and nonjudgmentally allowing the experience to unfold moment
by moment. In practice, meditative techniques are used to recognize
stresses, realize they are transiet, and allow them to pass.
Self-Determination Theory
(Ryan, Frederick, Lepes,
Rubio & Sheldon, 1997)
Exercise motivation is regulated by a range of intrinsic and extrinsic
factors. People who are more intrinsically motivated to perform a
behaviour are more likely to engage in and maintain that behaviour. This
theory describes how strongly a person is motivated by different forms of
regulation.
Social Cognitive Theory
(Demark-Wahnefried et al.,
2003; Rogers et al., 2009)
Focuses on cues to action, self-efficacy, and skill development centered
around the goals of changing the specific behaviour
Transtheoretical Model of
Behaviour Change
(Prochaska & Marcus,
1993)
Describes the stages of change for a behaviour, as well as factors that
influence behaviour, including: processes of change, self-efficacy and
decisional balance
Theory of Planned
Behavior
(Ajzen, 1991)
An individual’s intention to engage in a behaviour is influenced by their
attitude, subjective norm, and perceived behavaioural control. However,
intention does not always lead to actual behaviour. Therefore, strategies are
required to help individuals proceed from intention to execution of
behaviours. This is done by creating and using a specific action plan to
perform the behaviour.
63
Table 4
Summary of Interventions to Change the Physical Activity Levels of Breast and Prostate Cancer Survivors, which are Grounded in a Behavioural
Theory
64
Study
DemarkWahnefried et al.,
2003 (study
design)
AND
2007 (original
report of post
intervention
outcomes)
AND
Ottenbacher et al.,
2012 (first report
of follow up
results)
AND
Mosher et al., 2013
(second report of
follow up results)
N
Population
543 breast and
prostate
cancer
survivors
Behaviour theory
Social cognitive
theory and
transtheoretical
model of behavior
change
Intervention
12 month at-home intervention;
participants mailed a personally
tailored workbook, quarterly
newsletters, and a total of 23
counselling sessions delivered over
the phone. Workbooks generally
encouraged 15 minutes of strength
training every other day, 30 minutes of
aerobic exercise each day, as well as
dietary advice.
Results
From baseline to post intervention, the
intervention group significantly
increased PA levels compared to
controls (p = 0.02).
The intervention group maintained
their PA levels from post intervention
to follow up.
There were no significant differences
between intervention and control
groups for changes in self efficacy for
PA or barriers to PA. Changes in self
efficacy were significantly correlated
with PA levels.
65
Study
Hatchett, Hallam,
& Ford, 2013
N
74
Population
breast cancer
survivors
Behaviour theory
social cognitive
theory
Hebert, Hurley,
Harmon, Heiney,
Hebert, & Steck,
2012
47
prostate
cancer
survivors
Mindfulness based
stress reduction
Loprinzi et al.,
2012
69
breast cancer
survivors
transtheoretical
model of
behaviour change
Matthews et al.,
2007
36
breast cancer
survivors
social cognitive
theory
Intervention
12 week intervention: weekly emails
with behaviour advice for first 5
weeks, then 3 more fortnightly emails.
Participants also had access to an ecounsellor versed in exercise
prescription and the theoretical basis
of the intervention
12 weekly group sessions, lasting 2.5
hours each, to discuss and set health
goals, followed by monthly booster
sessions for the next three months (6
month total intervention)
12 month supervised exercise
intervention, delivered 3 days per
week. Results of follow up at 18
months (i.e. 6 months post
intervention)
6 telephone calls, at baseline and in
weeks 1, 2, 4, 7, and 10, to encourage
physical activity behaviours.
Compared to wait list control group
Results
intervention significantly increased
self reported total physical activity
compared to controls at 6 (p = 0.002)
and 12 (p < 0.001) weeks
compared to controls, intervention
group increased moderate and vigorous
physical activity hours per week as
measured by questionnaire (p = 0.006)
at the 3 month and 6 month assessment
self-efficacy and processes of change
at 12 months significantly associated
with self reported physical activity at
18 months.
intervention significantly increased
their physical activity as measured by
Actigraph compared to controls (p <
0.05)
Study
McGowan, North,
& Courneya, 2013
N
Population
303 prostate
cancer
survivors
Behaviour theory
theory of planned
behavior
Intervention
Participants mailed an information
packet (specifics determined by
random assignment to intervention,
described below), and were assessed
at baseline, 1 month, and 3 months.
Interventions:
Self-administered intervention group
received a packet of materials to teach
them to set physical activity goals and
advise them on how to achieve them
66
Telephone-assisted intervention group
received the same information as the
self administered intervention group,
but also were called by an exercise
counsellor to ensure they completed
the tasks and to help them do so if
needed
A control group was only mailed the
Physical Activity Guidelines for
Americans
Results
At 1 month, the self-adminstered group
significantly increased self-reported
total (p = 0.023) and moderate (p =
0.009) minutes of PA compared to the
controls. There was no difference
between groups for increase in minutes
of vigorous PA. The telephoneassissted group had similar PA level
changes for total and moderate to both
other groups.
At the 3 month assessment, groups
were not significantly different for
change in total, moderate, or vigorous
PA.
Study
Mefferd, Nichols,
& Pakiz, 2007
N
76
Population
breast cancer
survivors
Morey et al., 2009
(original report of
post intervention
results)
641 breast,
prostate, and
colorectal
cancer
survivors
Behaviour theory
cognitive
behavioural
therapy
social cognitive
theory AND
transtheoretical
model of
behaviour change
AND
67
2012 (report of
follow up results at
2 years after
baseline/1 year
post intervention)
Pinto, Frierson,
Rabin, Trunzo, &
Marcus, 2005
86
breast cancer
survivors
transtheoretical
model of
behaviour change
Intervention
16 weeks of weekly group sessions to
promote physical activity to combat
obesity
12 month at-home intervention;
participants mailed a personally
tailored workbook, quarterly
newsletters, and a total of 23
counselling sessions delivered over
the phone. Workbooks generally
encouraged 15 minutes of strength
training every other day, 30 minutes of
aerobic exercise each day, as well as
dietary advice.
12 week intervention, delivering
weekly phone calls to encourage
physical activity; goal was to perform
10-30 minutes on 2-5 days per week
of moderate intensity physical activity
at home. Compared to control group
who received weekly phone call to
complete Symptom Questionnaire
Results
non-significant increase in self
reported physical activity compared to
control group
From baseline to post intervention,
there was a significant difference
between the intervention and control
groups for duration and frequency of
both strength and endurance exercise
sessions.
From post intervention to follow up,
the intervention group maintained their
physical activity levels. At post
intervention, the wait list controls
started the intervention, and by follow
up and caught up to the original
intervention on levels of total PA.
intervention group engaged in more
minutes of physical activity as
measured by accelerometer than
controls (p < 0.001)
68
Study
Rogers et al., 2009
N
41
Population
breast cancer
survivors
Behaviour theory
social cognitive
theory
Vallance,
Courneya,
Plotnikoff, Yasui,
& Mackey, 2007
(results at post
intervention)
377 breast cancer
survivors
theory of planned
behavior
266
Intervention
12 week intervention, including: six
group discussion sessions to promote
behaviour modification; 12 individual
exercise sessions; three individual
counselling sessions reviewing social
cognitive theory constructs.
Intervention compared to control
group who were given
recommendations from American
Cancer Society
3 month intervention, with participants
randomizd to one of four
interventions: Standard
recommendations (n = 96); Specific
recommendations (n = 94); Pedometer
(n = 94); Combination pedometer and
specific recommendations (n = 93)
AND
Vallance,
Courneya,
Plotnikoff, Dinu, &
Mackey, 2008
(results at 6 month
follow up)
Followed up 6 months after
completing intervention. Samples at
follow up were: Standard
recommendations (n = 68); Specific
recommendations (n = 62); Pedometer
(n = 69); Combination Pedometer and
specific recommendations (n = 67)
Results
Intervention group had significantly
greater total physical activity than
controls as measured by accelerometer
(p = 0.004)
No difference between groups for
change in minutes of moderate (p =
0.63) or hard (p = 0.09) minutes of
physical activity
Specific recommendations increased
physical activity, but no more than any
other intervention
No difference between groups for
maintenance of physical activity
2.8.1 Measuring exercise motivation.
In the present study, two behavioral theories were used to understand and
influence the participants’ physical activity behaviours. The self-determination theory
(SDT) was utilized to measure exercise motivation, while the TTM was employed to
assist participants change their behaviour. The SDT describes that people are motivated
by a combination of intrinsic and extrinsic factors (Ryan et al., 1997; Standage et al.,
2008). In terms of exercise, intrinsic factors include enjoyment of the exercise, while
extrinsic factors include proposed and/or achieved health benefits or a structured
support network, such as an intervention program (Ryan et al., 1997). Observational
research has indicated that self-selected performance of higher intensity exercise is
correlated with higher intrinsic motivation (Duncan et al., 2010). Research has also
shown that long-term exercise adherence is dependent on strong intrinsic motivation
(Ryan et al., 1997). Little is known about how participating in high intensity exercise
might affect motivation, including whether it influences the intrinsic and extrinsic
components. The present study sought to explore if higher intensity exercise could
improve motivation to exercise to a greater extent than lower intensity exercise. This
directional hypothesis was based on the idea that engaging in high intensity exercise
should provide greater physiological gains for the participants and should be more
enjoyable, thus improving intrinsic motivation (Bartlett et al., 2011). Blaney et al.
(2010) found that a sense of achievement contributed to cancer survivors’ motivation to
exercise. Thus, cancer survivors who exercise at a high intensity may be more
motivated to continue because they experience a greater reward for their labours.
Two studies have examined specifically exercise motivation in cancer survivors
(Milne et al., 2008b; Milne et al., 2008c). Both were conducted by the same researchers,
and in the same metropolitan area as the present study. One was a cohort observational
69
study, while the other examined the effect of exercise on breast cancer survivors’
exercise motivation. These studies measured exercise motivation with the Behavioural
Regulation in Exercise Questionnaire Version 2 (BREQ-2). The BREQ-2 assesses four
extrinsic and autonomous motivational factors that contribute to exercise motivation.
Mullan et al. (1997) stated that external regulation and introjected regulation contribute
to extrinsic motivation (that is, the motivation to exercise that comes from outside an
individual), while identified and intrinsic regulations contribute to autonomous
motivation (that is, the motivation to exercise that comes from within an individual).
Autonomous motivation is the key to engaging in and maintaining exercise (Culos-Reed
et al., 2005; Loprinzi, Cardinal, Si, Bennett & Winters-Stone, 2012; Markland & Tobin,
2004; Milne et al., 2008a).
Table 5 displays the mean scores of Western Australian breast cancer survivors
(Milne et al., 2008b; Milne et al., 2008c). The relative autonomy index (RAI) is a
composite score that indicates overall exercise motivation, which can range from -24 to
20, with higher scores indicating greater exercise motivation. All the subscales range
from zero to four. For the extrinsic motivation factors, lower scores indicate that less
extrinsic influence is needed to exercise. For the autonomous motivation factors, higher
scores indicate a greater internal drive to exercise. The scores displayed in Table 5 can
be used to determine the clinically meaningful changes in the BREQ-2 and its subscales
among Western Australian breast cancer survivors.
70
Table 5
Exercise Motivation (BREQ-2) Scores of Western Australian Breast Cancer Survivors
Performing Different Levels of Physical Activity
Measure
RAI
Amotivation
External regulation
Introjected regulation
Identified regulation
Intrinsic regulation
Meeting PAG
13.2
0.3
0.5
1.1
3.3
3.2
Not meeting PAG
7.8
0.5
0.8
1.0
2.5
2.3
Sedentary
-13.1
3.6
3.6
1.5
1.4
1.2
Source: scores derived from Milne et al. (2008c) and Milne et al. (2008b).
As can be seen by comparing the scores of all the different groups, there are
large differences in the overall and extrinsic motivations between sedentary breast
cancer survivors and those who perform any physical activity, even if they are not
meeting the PAG. There are also large differences in the overall and autonomous
motivation between women who were and were not meeting the PAG. These
comparisons indicate that exercise participation is more dependent on autonomous
motivation; thus, autonomous motivation should be focused on helping cancer survivors
increase and maintain their physical activity levels (Milne et al., 2008a, 2008b; Milne et
al., 2008c). These results align with the theoretical constructs of the SDT, which predict
that autonomous motivation is the key to long-term exercise (Ingledew & Markland,
2008).
Observational research has shown that people who are more intrinsically
motivated to maintain their exercise regime self-select to exercise at higher intensities
(Duncan et al., 2010). One study in highly trained runners demonstrated that higher
intensity exercise was more enjoyable than moderate intensity exercise (Bartlett et al.,
2011). In contrast, other research has found that some people do not enjoy high intensity
exercise and will have a negative affective response to being forced to exercise at a
higher intensity than they would prefer (Parfitt & Hughes, 2009). Self-selection of
71
exercise intensity seems to be a key determinant of exercise enjoyment (Parfitt &
Hughes, 2009; Parfitt, Rose & Markland, 2000). When people are prescribed to exercise
at an intensity that is higher or lower than what they would have self-selected, they have
a more negative experience of their exercise session than when they are allowed to
control their exercise intensity (Parfitt et al., 2000). As enjoyment is a key part of
intrinsic motivation (Ingledew & Markland, 2008), it is important to examine whether
different prescribed exercise intensities influence cancer survivors’ exercise motivation.
2.8.2 Improving exercise adherence.
In their meta-analysis, Ferrer et al. (2011) discussed the importance of using
theory-based interventions to improve exercise behaviour change and help cancer
survivors maintain their behaviour changes beyond the life of the intervention. They
pointed out that only 19% of the studies in their meta-analysis explicitly used theory in
their exercise intervention development. A theory-based intervention uses the
framework of a recognised behavioural theory to determine the goals of the intervention
and the processes employed to achieve those goals (ACSM, 2006; Wood, 2008).
Although Ferrer et al. (2011) did not state which theories were used in the reviewed
studies, the theory that the ACSM (2006) supports is the TTM (Prochaska & Marcus,
1993). The TTM is discussed briefly below, and was used in the present study.
The TTM has four components: stages of change, processes of change, selfefficacy and decisional balance. The stages of change describe when a person is in the
process of adopting behaviour, from contemplating behaviour change, to starting to
engage in a new behaviour, to adopting and maintaining the behaviour. The TTM
postulates that if a behaviour is engaged in for six months, it is considered ‘adopted’,
and the person is then maintaining that behaviour (Milne et al., 2008a; Prochaska &
Marcus, 1993). For example, a sedentary person would be in the ‘contemplation’ stage
72
of exercise adoption when they request more information on an exercise program,
because they ostensibly intend to change their physical activity levels through
participation. Then, in the first few months of the exercise program, the person would
be in the ‘action’ phase. If the person exercised regularly for six months, they would be
considered to have adopted the exercise behaviour, and would be in the ‘maintenance’
phase, though a relapse to sedentary behaviour is unfortunately possible (Kim, 2007;
Prochaska & Marcus, 1993). One goal of the present intervention was to provide
structure for exercise in the initial action phase of behaviour change, to prepare
participants to continue to exercise on their own, and to then assess participants six
months after enrolment to determine if they had adopted and were maintaining their
levels of physical activity.
Aside from describing exercise behaviours through the stages of change, the
TTM can be used to influence the adoption and maintenance of intentional health
behaviours by employing processes of change (Nigg & Riebe, 2002). To influence
exercise adoption and maintenance, an intervention needs to employ behavioural change
techniques because ‘the explicit use of theory will improve chances of effectiveness’ of
an exercise program (Hutchison et al., 2009, p. 829). The processes of change describe
the overt and covert cognitive and behavioural activities that modify behaviour. In
exercise research, the TTM has been used to describe the cognitive and behavioural
strategies that people use to engage in exercise (Kim, 2007; Nigg & Riebe, 2002;
Prochaska & Marcus, 1993). Research has previously determined that behavioural
processes of change are the most important aspect of the TTM to focus on to maintain
exercise (Burbank, Reibe, Padula & Nigg, 2002; Kim 2007; Loprinzi et al., 2012). Kim
(2007) identified the most important processes of change as counter-conditioning and
helping relationships, while Burbank et al. (2002) also included reinforcement
73
management. Examples of these behavioural processes include making a plan to resist
the temptation to skip exercise sessions, joining a support group or having exercise
buddies, and providing meaningful rewards for long-term regular exercising,
respectively (Burbank et al., 2002).
The remaining two components of the TTM are self-efficacy and decisional
balance. Self-efficacy describes the belief of a person that they can accomplish the
desired behaviour. Decisional balance states that, for behaviour to be adopted, the pros
of adoption must outweigh the cons (Kim, 2007; Prochaska & Marcus, 1993). Although
not measured in the present study, using the behavioural processes of change may help
people improve these two factors as part of their progression towards exercise behaviour
maintenance (Nigg & Riebe, 2002; Prochaska & Marcus, 1993). The gap in the
knowledge is: how can short-term (two- to three-month) exercise interventions
influence exercise motivation so that people become lifelong adopters of exercise?
2.9 Gender Differences and Exercise
Researchers have documented the anatomical and physiological differences
between men and women (Billaut & Bishop, 2009; Collier, 2008; Gillum, Kuennen,
Schneider & Moseley, 2011; Harms, 2006; Numao, Hayashi, Katayama, Matsuo &
Tanaka, 2009; Reybrouck & Fagard, 1999). One review article grouped the major
gender differences that pertain to exercise into six categories: body composition,
endocrine status, enzyme activities, substrate use, muscle fibre properties and neural
activation (Billaut & Bishop, 2009). As most men are proportionally larger than most
women, especially in lung and heart volume, they typically can achieve higher absolute
levels of cardiorespiratory fitness (a higher VO2peak) (Billaut & Bishop, 2009; Collier,
2008; Harms, 2006; Reybrouck & Fagard, 1999). Due to these anatomical differences,
men and women achieve the same absolute cardiac output by different mechanisms—
74
while men tend to have a larger stroke volume, women have a more rapid HR (Billaut &
Bishop, 2009; Collier, 2008; Harms, 2006; Reybrouck & Fagard, 1999). It has also been
documented that men and women develop CVD through different pathological
pathways (Collier, 2008; Foryst-Ludwig et al., 2011). Related to this difference, Collier
(2008) highlighted that men and women do not respond the same to antihypertensive
pharmaceuticals, with these drugs being less efficacious in women. Research also
indicates that women may experience a greater protective benefit of physical activity
against CVD than men (Sattelmair et al., 2011). Additionally, regular lifetime physical
activity may reduce the risk of breast cancer more so than prostate cancer (Friedenreich,
Neilson & Lynch, 2010).
Despite these gender differences, Billaut and Bishop (2009) stated that many
reported gender differences are ‘due to inappropriate comparison methods rather than
actual sex differences’. The presence of oestrogen, the menstrual cycle phase and oral
contraceptive usage are major confounders of comparisons between the genders.
Gender-based endocrine differences are difficult to account for in many human studies,
and have profound effects on most physiological systems in men and women.
Researchers have highlighted other important traits—besides oestrogen and different
lung and heart size—that need to be controlled. These traits are not exclusive to women,
but are commonly skewed between the sexes (Billaut & Bishop, 2009; Gillum et al.,
2011; Harms, 2006; Numao et al., 2009; Robertson et al., 2000). Women typically have
more adipose mass and less lean muscle mass relative to total body mass, and
participate in less vigorous exercise activities than men (Billaut & Bishop, 2009; Gillum
et al., 2011; Harms, 2006; Numao et al., 2009; Robertson et al., 2000). When
confounding factors are accounted for, researchers have reported finding few or no
differences between genders on outcomes such as exercise ability or CVD and
75
metabolic disease risk (Billaut & Bishop, 2009; Collier, 2008; Gillum et al., 2011;
Harms, 2006; Reybrouck & Fagard, 1999). For example, Harms (2006) pointed out that
when lung size and fitness level are accounted for, the gender differences in the
respiratory system physiology are negated.
Additionally, experimental and observational research has found no gender
differences on an array of outcome measures during and after exercise (Astorino et al.,
2011; Bartholomew & Linder, 1998; Carter, Rennie, Hamilton & Tarnopolsky, 2001;
Numao et al., 2009; Robertson et al., 2000; Weber & Schneider, 2002). During exercise,
there were no differences between men and women on compliance to relative exercise
intensity achieved; affective response to or ratings of perceived exertion of different
aerobic and resistance exercise intensities; or epinephrine, norepinephrine, insulin and
serum free fatty acid levels (Bartholomew & Linder, 1998; Numao et al., 2009;
Robertson et al., 2000). Additionally, several studies have observed no adaptation
differences between men and women to chronic exercise training on the following
parameters: VO2peak, 3-βhydroxyacyl CoA dehydrogenase, citrate synthase, succinatecytochrome c oxidoreductase, cytochrome c oxidase and maximal accumulated oxygen
deficit. The latter is an accurate method of quantifying an individual’s anaerobic
capacity, as it is a surrogate to the direct measurement of maximal adenosine
triphosphate produced through anaerobic metabolism (Astorino et al., 2011; Carter et
al., 2001; Weber & Schneider, 2002). Of particular relevance to the present study,
Astorino et al. (2011) determined that there were no differences between men and
women in VO2peak change after participating in a high intensity aerobic exercise
program.
Two other studies that were more epidemiological in nature are important to
consider. Both these studies examined exercise intensity and risk of CVD, one in men
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(Tanasescu et al., 2002) and one in women (Manson et al., 2002). Both studies showed
that men and women significantly lower their risk of developing CVD more through
vigorous exercise than through lower intensity exercise (Manson et al., 2002; Tanasescu
et al., 2002). To add further to the discrepancies in the literature are studies that show
gender similarities in some acute immunological responses to exercise and differences
in other inflammatory indices, such as the results of the study by Stupka et al. (2000).
Together, these studies highlight both the similarities and differences in how
healthy men and women adapt to exercise. However, little research to date has directly
compared male and female cancer survivors to see if treatment changes in their
physiology mitigate exercise adaptation. For example, prostate cancer survivors who
undergo ADT experience a range of side effects that may compromise their adaptation
to exercise (Hakimian et al., 2008). Only one study was found that reported comparing
breast and prostate cancer survivors’ responses to an exercise intervention, and the
authors stated that there were no differences to any physiological or psychological
responses between the cancer populations (De Backer et al., 2007). This lack of
differences may have been due to imbalanced samples (n = 13 males and 44 females).
More research is needed to determine if breast and prostate cancer survivors respond
similarly to the same exercise intervention.
2.10 Summary
Despite evidence showing that physical and psychological interventions improve
QOL in cancer survivors, there is a need for more specific guidelines on exercise
prescription. Retrospective and meta-analytic evidence among cancer survivors has
highlighted that there may be a dose response between the intensity of exercise
performed and increases in survival and QOL. High intensity exercise has been shown
to be safe and effective to use in some cancer and CVD populations. However, no
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comparative prospective study has demonstrated that higher intensity exercise, within
the context of a group exercise and SGP intervention, can provide greater or more
enduring increases in QOL than exercising at a lower intensity. Likewise, higher
intensity exercise may have greater benefits for cancer survivors’ motivation to continue
exercising beyond the duration of a structured program.
In the main study of the current research, the effect of manipulating prescribed
exercise intensity on physiological and psychological outcome measures was assessed.
First, however, the pilot study is presented to justify the feasibility of conducting the
main study and recruiting prostate cancer survivors to the intervention.
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Chapter 3: Pilot Study
Previous studies have examined interventions that combine exercise and
psychological counselling to rehabilitate cancer survivors (Berglund et al., 1993; Block
et al., 2009; Cho et al., 2006; Courneya et al., 2003a; Culos-Reed et al., 2007; Naumann
et al., 2012a; Rabin et al., 2009; Van Weert et al., 2005). Their findings suggest that a
multimodal approach may address several dimensions of QOL and subsequently
provide cancer survivors with greater improvements in overall QOL (Naumann et al.,
2012a). To date, multimodal interventions have been predominantly delivered to female
cancer survivors, so it is unclear if such an intervention would also be suitable for men.
Mental health interventions remain underused in oncology, especially among
men (Carmack Taylor et al., 2006; Eakin & Strycker, 2001; Kaplan, 2008; Krizek et al.,
1999; Nekolaichuk et al., 2011; Petersson et al., 2000; Sherman et al., 2007; Steginga et
al., 2008). This appears to be more by preference, rather than due to a lack of available
services (Carmack Taylor et al., 2006; Krizek et al., 1999; Nekolaichuk et al., 2011;
Petersson et al., 2000; Sherman et al., 2007). Barriers among prostate cancer survivors
to accessing psychosocial support include:
1. a sense of stigma and therefore social constraint from seeking mental health
service (Kaplan, 2008; Steginga et al., 2008);
2. the failure of healthcare providers to ask about emotional distress (Kaplan,
2008; Plass & Koch, 2001);
3. a lack of awareness among survivors of the available resources in their
community (Eakin & Strycker, 2001; Kaplan, 2008; Plass & Koch, 2001);
4. men simply not believing that they require mental health services (Boudioni
et al., 2001; Eakin & Strycker, 2001; Krizek et al., 1999; Plass & Koch,
2001; Sherman et al., 2007).
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When prostate cancer survivors do participate in psychological support services,
they identify the most valuable component as being the information presented on their
medical and health outcomes (Berglund, Petersson, Eriksson & Häggman, 2003;
Boudioni et al., 2001; Sherman et al., 2007). Stress management techniques are also
highlighted as another highly appreciated component of mental health interventions
(Chambers, Pinnock, Lepore, Hughes & O’Connell, 2011). More stereotypical
counselling areas, such as communication or psychological reaction to an event or
situation, are rated lower in importance and preference or are avoided by men altogether
(Berglund et al., 2003; Boudioni et al., 2001; Sherman et al., 2007). This has been
attributed to the male view that sharing emotions is uncomfortable and undermines their
masculinity (Roth, Weinberger & Nelson, 2008). A seminal study in this area,
conducted by Krizek et al. (1999), demonstrated that once a prostate cancer survivor
actually commits to attending the first support group session, he tends to stay with the
program—the challenge is ‘getting them in the door’.
Previous research has found that combining individual counselling with
personalised exercise for breast cancer survivors was both feasible and acceptable for
breast cancer survivors, and that it improved QOL more than using the single entities
(Naumann et al., 2012a). The purpose of the current research’s pilot study was to
examine if the multimodal group intervention was feasible and acceptable to both breast
and prostate cancer survivors, and to trial some physiological and QOL parameters to
determine if the tools were able to capture the physiological and psychological
responses to the intervention. Participant experiences of and feedback on the program
were obtained in order to refine the intervention for use in the main phase of the
research.
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3.1 Methods
3.1.1 Participant recruitment.
Prostate and breast cancer survivors were recruited to participate in a group
exercise and SGP program through flyer distribution at hospitals, the Breast Cancer
Associations, the Fremantle General Practitioner (GP) network, urology offices and
physiotherapists in the Perth metropolitan area, as well as through letters to Hospital
Benefits Fund members. Additionally, referral forms were mailed directly to
oncologists. To be included in the study, participants had to:

be 25 to 80 years old

have confirmed Stage I, II or III breast or prostate cancer

have completed all planned surgery, chemotherapy and/or radiation therapy
(participants receiving adjuvant hormone therapy were still eligible)

be able to participate in exercise as determined by a physical activity
readiness questionnaire (PAR-Q) or clearance from their physician.
Potential participants were excluded if they had an acute or chronic bone, joint or
muscular pain or abnormality that would compromise their ability to complete the
exercise program; had metastatic breast or prostate cancer; were unable to understand
written or verbal English; or were not cleared by their physician to participate in the
exercise program.
The interventions began on a rolling basis from June 2010 until October 2010,
with the last group finishing in December 2010. Men and women participated in
separate groups. The group interventions had set start times, and patients who could
meet those times were assigned to the group that fit their schedule. A new group started
when the registration of interest for the group reached at least six people. Before the
intervention, participants completed pre-exercise screening and assessments. During
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this session, the structure of the intervention was reviewed and the participants had the
opportunity to ask any questions about the program. All eligible subjects who enrolled
signed an informed consent form approved by the University of Notre Dame Australia
Ethics Committee. This study was approved by the University of Notre Dame
Australia’s Human Research Ethics Committee (#08002F).
3.1.2 Outcomes.
3.1.2.1 Feasibility.
Feasibility was set as participant attendance to both components and retention
rates to the study of at least 80% (Martin, Battaglini, Groff & Naumann, 2013).
3.1.2.2 Physiological assessments.
Vitals and body composition were measured after at least five minutes of rest.
Resting HR was measured from the reading of a Polar HR monitor (Kempele, Finland).
Blood pressure was measured by a 3M™ Littman stethoscope (Minnesota, USA) and
sphygmomanometer (ABN Healthcare Systems, Padalarang, Indonesia). Height was
measured in centimetres with a wall-mounted stadiometer, with participants standing
with their shoes off and head held in the Frankfort plane. Weight was measured in
kilograms with an A&D Weighing scale (California, USA), again with the participants’
shoes off. Body composition was determined by a four-site skinfold measurement, using
a Harpenden Skinfold Caliper HSK-B1 (British Indicators, West Sussex, UK). The sites
used were triceps, suprailiac, abdominal and thigh. The four-site equation for
determining body fat percentage (BF%) from these measures was developed by Jackson
and Pollock (1985).
The Modified Bruce Treadmill Test was used as a submaximal test to estimate
cardiorespiratory fitness (Bruce, 1971). This test uses a graded protocol to assess how
long a participant can walk or run on the treadmill until they reach 75% of their
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predicted maximum HR (calculated as 220 - age). The Modified Bruce Treadmill
Protocol has been reported as being valid and reliable (r = 0.94 to 0.96 for correlations
between predicted and measured VO2max; Bruce, Kusumi, & Hosmer, 1973; Foster et
al., 1984). Participants wore a Polar HR monitor during the test to accurately determine
when their target HR was reached. The test was terminated when the participants
reached their target HR, wished to stop or could not progress to the next stage of the
test. Lower body strength was assessed through a 1RM leg press test (ACSM, 2006)
using a SportsArt A956 horizontal leg press machine (Tainan City, Taiwan). One
repetition maximum testing for the leg press has been found to be valid (r = 0.72 – 0.77;
Verdijk, van Loon, Meijer, & Savelberg, 2009) and reliable (r = 0.89; Hoeger, Hopkins,
Barette, & Hale, 1990).
3.1.2.3 Quality of life.
The participants completed the appropriate Functional Assessment of Cancer
Therapy—Prostate (FACT-P) or Breast (FACT-B) questionnaire to assess their cancerspecific QOL, both of which include the General (FACT-G) questionnaire (Brady et al.,
1997; Esper et al., 1997).
3.1.3 Intervention.
The multimodal intervention lasted eight weeks and consisted of group exercise
and SGP. Group exercise was delivered by the researcher for three days per week, for
one hour each session. The SGP was delivered by two accredited counsellors once per
week for 60 to 90 minutes. All exercise sessions included 20 to 30 minutes of aerobic
training (walking outside, cardio machines, boxing or water aerobics), 20 to 30 minutes
of resistance training (weight lifting, body weight exercises or hydrotherapy
strengthening exercises), and 10 minutes of flexibility training (static stretching). The
exercise prescriptions were individualised to the needs of the group members.
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The SGP program was developed and formalised by counsellors from the
University of Notre Dame Australia’s School of Counselling who provided the
counselling service for the breast cancer survivors in the previous study (Naumann et
al., 2012a). The lead counsellor had previously worked for several decades as a urology
nurse, and thus adapted the SGP program’s components, which were breast cancer–
specific, to address prostate cancer–specific concerns as well. The development of the
SGP intervention was based on the classic work of Cain et al. (1986), which developed
formal models of group psychological interventions in cancer survivors. Each weekly
session was based around a theme. These themes reflected the ongoing needs of cancer
survivors after completing treatment (Jefford et al., 2008; Marlow, Cartmill, Cieplucha
& Lowrie, 2003). The topics used were: 1) exploring life stories, 2) implications of
living with cancer, 3) coping with stress, 4) mindfulness and feeling anxious, 5)
relationships and support, 6) self-identity, 7) hope, and 8) moving forward.
Each SGP session employed a combination of individual expression, group
discussion, and teaching and problem solving, which was led by both the counsellors
and the participants (Breitbart, 2002; Breitbart et al., 2010; Cain et al., 1986). The
proposed benefits to the group of participating in these experiences together were
creating a sense of belonging and normalcy, sharing and reshaping their identities,
feeling a sense of mutual aid, and creating hope by comparison of coping success. The
overarching aims of the SGP, as reflected in the structure of the weekly themes, were to
help people cope with their cancer experience, focus on other life issues tangential to
the cancer experience, and prepare themselves to move on towards normal.
3.1.4 Procedures.
The participants were screened and assessed prior to the start of the intervention.
The intervention lasted eight weeks. Post-intervention assessments were conducted the
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week after the intervention completed. Group feedback sessions were held the week
following the post-intervention assessments.
3.1.5 Qualitative analysis.
To examine the participants’ experiences and feedback on the intervention,
qualitative data were gathered during group feedback sessions. Each group was
interviewed after all members had completed their post-intervention assessments.
Groups, and therefore genders, were not mixed but interviewed separately. All feedback
interviews were conducted by the same researcher. An interview schedule was
developed as a flexible guide to the focus group sessions (Appendix D). The core topics
included the overall experience of the program, experience specifically of the SGP
sessions, experience specifically of the exercise sessions, interactions between the
intervention components, and recommendations to change the intervention. To start the
discussions, the facilitator asked the participants to describe their overall experience of
participating in the program. The patients were then encouraged to comment on each
other’s opinions, to elaborate more on opening statements, or to expand their thoughts
based on the topics in the interview schedule. The sessions lasted 90 minutes and were
audio-recorded. The recordings were then transcribed verbatim.
Qualitative research method experts have commented that conducting focus
groups, rather than individual interviews, may lead to some members of the group
dominating or influencing others (Wilson, 2012). However, in this case, the benefit of
having the opportunity for participants to support and elaborate or provide an alternate
viewpoint on topics brought up by each other seemed to outweigh any possible
impediments. Additionally, it was deemed that after 8 weeks of group discussion in the
SGP sessions, the members would be able to respectfully and collaboratively give
feedback together. Though individuals did not have the opportunity to officially give
85
feedback in private, the participants had spoken to the researcher about matters
important to them throughout the course of the program. The researcher attempted to
prompt individuals who had previously informally given opinions that may have been
useful to the discussion.
Interpretative phenomenological analysis, based on the methods detailed by
Smith et al. (2001), was employed to make sense of the participants’ experiences. Smith
et al. (2001) stated that, in interpretative phenomenological analysis, a dual
interpretation process is engaged between the researcher and the participants. First, the
participants are making sense of their experiences by articulating them and discussing
them with each other. Second, the researcher is actively involved in interpreting the
participants’ shared experience—in this case, through transcriptions of the focus group
interviews. This dynamic process requires that the researcher use his or her own
conceptions of the world and the participants’ situations in order to create meaning out
of the participants’ experiences. The rational for using Interpretative Phenomenological
Analysis is that it is an approach to psychological qualitative research with an
idiographic focus (Smith et al., 2001). It aims to offer insights into how a given person,
in a given context, makes sense of phenomena discussed. In the current thesis, the
phenomena of interest are the individuals’ experiences with cancer, considered a major
life event of personal significance.
NVivo Version 8 (QSR International, VIC) was used to facilitate the
interpretative phenomenological analysis. Transcript texts were loaded as sources into
the NVivo software to allow for direct coding, grouping of the codes into connections,
and grouping of the connections into themes. Following the procedures outlined by
Smith et al. (2001), transcriptions were first read to identify emerging themes. These
initial themes were used to create an initial set of codes (for example, ‘shared
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experience’). The transcripts were then re-read, with the initial codes applied throughout
the second reading. Individual comments were coded contextually to identify
commonalities in meanings, situations and experiences, and, in the parlance of
interpretative phenomenological analysis, these are considered meaning units. As new
meaning units were identified and new codes created, the transcripts were continually
re-read in an iterative process to ensure that all codes were applied throughout the entire
document where appropriate. Additionally, new codes were created and applied as
connections emerged between meaning units.
The connections described recurrent themes that were expressed in different
ways by the participants (for example, ‘effect of exercise on shared experience’ or
‘effect of counselling on shared experience’). If pertinent, multiple codes were assigned
to a statement or phrase to ensure the data were analysed for all possible themes and
connections (for example, ‘effect of exercise on shared experience’ and ‘effect of
exercise on sexuality’). The connections were categorised to develop the overarching
themes to construct an overall representation of the patient’s experiences of the
program. This thematic analysis was enhanced by extracting examples from the
transcripts, including the surrounding context, to clarify the participants’ responses and
demonstrate their lived experiences in their own words. The analyses continued until
saturation of the data was reached.
3.1.6 Statistical analysis.
The quantitative data were analysed using SPSS Version 20 (IBM, Armonk,
USA). Only data from participants who completed both assessments were analysed.
Descriptive statistics were generated for the participant’s age, cancer stage, months
post-treatment, treatment undertaken, height, resting blood pressure, resting HR and
attendance to exercise and SGP sessions, which were presented as a percentage of the
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sessions attended. Changes in weight, body composition, estimated cardiorespiratory
fitness, lower body strength and QOL scores were assessed using repeated measures
analysis of variance (ANOVA).
3.2 Results
3.2.1 Participant characteristics.
Sixty-seven people registered interest in participating in the study. The two most
common reasons for not enrolling were that the operating times did not align with their
schedule, or that they did not wish to travel to the site. Two participants did not meet the
eligibility criteria. One had suffered a knee injury that required anterior cruciate
ligament reconstruction, and therefore would not have been able to complete the
exercise, while the other had cancer of the tongue. In total, 31 participants (12 men and
19 women) enrolled.
Throughout the program, three people dropped out after the initial assessment.
One woman suffered a back injury prior to the assessment and decided to not
participate. Another woman came to her assessment, but never returned. In a follow-up
telephone call, she disclosed that she lacked the motivation to force herself to make the
commitment. One man withdrew six weeks into the program after suffering a heart
attack. Seventeen breast and 11 prostate cancer survivors completed the program and
were analysed. The patient characteristics at baseline are shown in Table 6.
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Table 6
Pilot Study Participant Characteristics
Prostate cancer
survivors
(n = 11)
M (SD)
59.4 (5.1)
22.4 (19.3)
175.0 (5.8)
134.8 (17.8)
83.2 (6.5)
67.8 (8.2)
Measure
Age (years)
Months post-treatment
Height (cm)
Resting systolic blood pressure (mm Hg)
Resting diastolic blood pressure (mm Hg)
Resting HR (beats per minute [BPM])
n (%)
Stage of cancer
I
II
III
Underwent lumpectomy
Underwent mastectomy
Received chemotherapy
Received radiotherapy
Received/receiving hormone therapy
Underwent prostatectomy
Received radiation (either external beam or brachytherapy)
Underwent/undergoing ADT
Breast cancer
survivors
(n = 17)
M (SD)
56.5 (9.2)
11.5 (14.1)
164.5 (4.9)
125.7 (21.3)
83.2 (11.9)
77.3 (8.6)
n (%)
2 (18)
7 (64)
2 (18)
2 (12)
12 (70)
3 (18)
3 (17)
11 (65)
10 (59)
9 (53)
6 (35)
10 (91)
4 (36)
2 (18)
3.2.2 Feasibility.
Of the 67 potential participants, 31 (46%) enrolled in the study and 28 (90%)
completed the whole program. The women had an average attendance rate of 85% for
both the exercise and SGP sessions, while the men attended an average of 80% of the
exercise sessions and 87% of the SGP sessions. Among the women, the reason for
missing days was mostly due to minor illness. One woman missed 11 sessions due to
surgery, but was able to return for the final weeks of the intervention. Among the men,
the majority of time away from the program was due to work.
3.2.3 Outcome measures.
The participants did not significantly change between assessments on weight (p
= 0.58) or body composition (p = 0.06). Overall, the participants improved their
estimated cardiorespiratory fitness (p = 0.002), with breast cancer survivors making a
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greater improvement than prostate cancer survivors (time*cancer type: p = 0.022). On
average, the participants increased their leg press 1RM (p < 0.001), with prostate cancer
survivors making significantly greater improvements than breast cancer survivors
(time*cancer type: p = 0.001). There were no significant changes on the FACT-G scores
(p = 0.11) and no difference between cancer types for change (p = 0.45). The prostate
cancer survivors did not significantly improve their cancer-specific QOL (p = 0.39),
whereas the breast cancer survivors did (p = 0.007) (Table 7).
Table 7
Baseline and Post-intervention Outcome Scores from Pilot Study
Prostate cancer survivors
(n = 11)
Measure
Baseline
M (SD)
Post-intervention
M (SD)
Breast cancer survivors
(n = 17)
PostBaseline
intervention
M (SD)
M (SD)
76.5 (16.6)
75.9 (16.0)
Weight (kg)
86.6 (11.3)
86.6 (11.0)
Body composition
24.7 (6.8)
23.9 (6.0)
35.5 (9.8)
32.4 (7.5)
(BF%)
Estimated
cardiorespiratory fitness
34.7 (9.0)
36.0 (6.6)*a
23.5 (10.2)
31.5 (7.7)*a
(mL/kg/min)
Leg press 1RM (kg)
119.1 (37.0)
172.3 (71.0)*a
91.2 (45.7)
97.1 (42.7)*a
FACT-G score
79.6 (16.5)
81.6 (13.8)
79.6 (14.3)
85.1 (13.1)
FACT-P or -B score
110.2 (22.4)
115.2 (20.3)
100.7 (15.3)
108.1 (15.4)*
Note: * significant change from baseline to post-intervention. a significant interaction between cancer
type and time.
3.2.4 Narrative feedback.
All of the men and 14 of the women participated in the group feedback
interviews. Three women missed due to scheduling conflicts. The data presented here
focused on the feedback pertinent to the program design. Nineteen individual categories
were initially identified and coded. These were connected into seven major themes that
highlighted the value of the program for the participants. The seven themes were:
1. an opportunity to explore and redefine self-identity
2. support to succeed, despite prior failures
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3. the importance of exercise variety
4. the value that the combined exercise and counselling model offered the
participants
5. changing perceptions of counselling
6. the importance of participating in the program as a group
7. the importance of maintaining exercise behaviours.
3.2.4.1 An opportunity to explore and redefine self-identity.
All the participants were in the process of redefining and coming to terms with
an altered self-identity. The biggest change felt among the men and women was that
society now labelled them a cancer survivor. One woman said, ‘I don’t want to say I’m
a breast cancer survivor. I don’t want to be known as that, I just want to be me’.
Sexuality and body image were the other big factors in self-identity. For both
men and women, the treatments impaired sexual function and desire, which distressed
them greatly. Some women commented on how they felt extra guilt because they knew
their loss of sexual ability was depriving and frustrating their partner. For the women,
losing one or both breasts and gaining fat mass negatively changed their body image,
which subsequently decreased their libido. For the men, gaining fat mass worsened their
body image. However, they focused their changes in sexuality directly on their inability
to have and maintain an erection. For the men, sexuality and self-identity conjoined to
create their notion of manliness. One participant stated:
It’s a stigma. It’s a social stigma. You talk about your manhood—it’s what
hangs between your legs—and then all of a sudden if that’s not working
properly, you know psychologically that impacts about how you feel.
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3.2.4.2 Support to succeed, despite prior failures.
The participants’ previous attempts to improve their fitness had often met with
failure. Some of the barriers described were pain: ‘the barrier of going to the gym with
all the gym bunnies, etcetera, is very daunting because you’ve got that low self esteem’
and not knowing what exercises to do or which ones may cause further complications
after treatment. Many of the women shared a similar sentiment to the participant who
stated, ‘If I went to a gym and said I’m a breast cancer survivor … I wouldn’t feel
comfortable with the other people’. In contrast, at the clinic, ‘you’re not seen, for want
of a better word, as an oddity’.
Participants found the lack of mental health support frustrating. One woman
described the support group sessions available through the breast cancer foundation as
‘once a month … and I hardly know anyone, and we don’t touch on anything really
useful’. One man had a unique perspective on what support was available to prostate
cancer survivors in the Perth area:
I’ve run a support group for almost 18 months with two other conveners. I’ve
mentioned a little bit here about how I feel about the ineffectiveness of support
groups with PCFA [Prostate Cancer Foundation of Australia]. And I feel very
frustrated because I don’t see an improvement down the track … and that is
wrong, because they’ve spoken about if for ages—about getting prostate cancer
nurses trained up to help guys from the word go. The moment of diagnosis, there
is your specialist medical person, holistically trained, to get hold of person A
and say, ‘okay, you’ve been diagnosed. I’m your link to the medical profession.
We meet once a week whenever you need and I just give you information and
contacts and professional support’. Not there … The support group people, who
are not medical people, not allowed to give advice, not allowed to counsel, we’re
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on the other end of the telephone, trying to help people, not quite sure how to do
it. It’s not good.
3.2.4.3 The importance of exercise variety.
In the pilot study, the researcher employed a variety of modes of exercise to
determine which ones the patients enjoyed and found beneficial, or whether any modes
seemed unsuitable. The exercises included resistance circuits using free weights,
resistance bands and weight machines; general cardio, such as walking outside, walking
up and down stairs, or using cardio machines; cardio boxing classes; hydrotherapy; and
core, Pilates and yoga exercises.
All the participants identified the variety of activities as paramount for their
enjoyment and accomplishments in the program. They repeated how their health was
not just related to the areas in which they had received surgery, such as their pelvis or
chest, but to their whole body. The variety of exercise allowed them to work on all
aspects of fitness for all parts of their body.
I so appreciated the range of exercises, I’ve now got a whole host. And I never
used to do flexibility and that in the gym, now I’m gonna go there and do both.
So I’m really rapt that I’ve got the overall that I’m gonna enjoy and it’s gonna
benefit me.
Perhaps even more important than the different accomplishments was the
motivation: ‘I loved the idea of it being, well, what the hell’s gonna happen next time?’
The patients stressed the importance of variety to keep them motivated and challenged,
and speculated that ‘the drop-out rate would be very high if it was the same thing every
day, people would be really bored’.
Many patients found the resistance training to be the most important part of the
program from an educational and novelty perspective. One woman commented that the
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weights were ‘really challenging, but it was a real sense of achievement, which I really
liked it ‘cause I found it quite hard’. Often, the patients performed circuits of resistance
exercises ‘and I found when we did circuits, I was really motivated ‘cause it was
moving quickly’. Another reason the patients identified that the resistance training was
so important was that many of them had little experience in resistance training, and
learning this new mode of exercise helped them reach their goals of improving strength
and body composition. They also felt they could not have performed resistance training
safely and effectively on their own without having been taught at this program, whereas
they could have performed aerobics and stretching on their own.
Though many participants thought resistance training was the most important
part of the intervention because of their need for instruction in technique, cardiovascular
fitness was viewed by most participatns as one of the most important and common
exercise modes to perform under all circumstances. After diagnosis, many people
reported that their doctor told them they needed to get outside and walk as the minimum
exercise, but they could never motivate themselves to do it. Being at a program with the
sole purpose of exercising provided the structure they needed. For more intense cardio
sessions, the staff led participants through cardio boxing workouts. While, at first, this
seemed strange to the participants, by the end of the program, both the men and women
stated, ‘I loved the boxing for the full workout and cardio’.
Hydrotherapy was introduced with the first group because one woman’s arthritis
was reacting so badly that she felt uncomfortable performing any exercise on land early
in the program. The low impact of the water allowed her and the other men and women
to exercise more intensely than they could on land. The participants described how
exercising in the water never felt strenuous in the moment, but the next day, they felt as
though they had been working just as hard as when doing exercises on land. Even when
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they could not articulate how the hydrotherapy benefited them, the participants
described it as ‘fantastic’, ‘very good’ and ‘really important’. They described
hydrotherapy as a fun way for them to relax, bond and act a little silly.
The program delivered different forms of core work, from mat work and using
fitness balls to Pilates and yoga routines. Most participants found these to be the most
challenging exercises. The men especially wanted the core work to help strengthen the
pelvic floor and deep stabilisers because they had been told these would help any
incontinence issues they might experience.
Most sessions were completed inside the clinic facility; however, the trainers
would take participants outside about once each week. One session that was always
used in the first week as an introduction was to walk around the neighbourhood to help
the participants find the pace necessary to improve cardiovascular endurance. The walk
lasted 20 to 30 minutes, followed by a series of resistance, core and balance exercises
performed with no equipment, except a nearby wall or bench. At the end of the
program, some of the patients commented specifically on this workout and how it
changed their view of exercise. One participant stated:
One other thing I thought was beneficial was the outdoor stuff, ‘cause I do a lot
of walking. And those exercises where you use whatever’s around, the wall or
something to do your squats, plus being out for fresh air. I think anybody can
benefit from that, ‘cause they’re walking, they know what to do, whereas
something you probably wouldn’t even think about to do if you walked pass a
wall, so I found that beneficial.
Another man commented further about the increased awareness of ‘the
physicality of our life’. He told an anecdote, ‘The other day, I was walking along with
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the basket full of produce, and I was doing this [mimics bicep curls]—oh fucking hell,
what’s happening? So I think we’re becoming more aware of the virtues’.
3.2.4.4 Value that the combined exercise and counselling model offered
participants.
There was strong support for the combined nature of the program, whereby
exercise was perceived to facilitate the counselling. Many suggested that they would not
have sought out counselling, but found it very helpful. Some stated that they had
suppressed their feelings regarding some issues without realising it until these issues
were discussed during the SGP. The program assisted the participants to deal with these
issues and move forward. The participants described what the program meant to them,
and how their lives changed from the program. One participant stated, ‘I feel like I’ve
actually taken control and hopefully will continue to get it back on track. And that
obviously helps your wellbeing’.
A resounding theme in their conversations was the interdependence of physical
and mental wellbeing for total QOL. While describing the decreases in health and
fitness experienced since her diagnosis, one woman stated, ‘I think that plays a big part
in the mental anguish of going through cancer, because the mind and the body are
totally connected’. In describing how the exercise improved more than just their
physical health, some men stated:
You’re pushing the envelope in your own personal physical continue, and then
suddenly you begin to find out that it goes further. And for me, my sense of self,
and my sense of manhood … this is terrific.
Being here has given me that boost, and that’s been connected also to that side
of who I am as a person. As a male, that side has been reaffirmed. And that’s
helped, the fact that the other bit of it [erections], has not been. But [the
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program] has also given me the confidence that that side of it has got some hope,
because being more physically fit and sort of heart rate and all that sort of stuff,
that’s all gonna help.
Other major benefits described were having more control and focus in their lives,
having a kickstart to a healthier lifestyle, and having something to look forward to three
mornings each week.
Aside from the mind–body connection, the patients also felt that the act of
exercising together allowed them to participate in counselling together:
If you look at prostate cancer it sets people back a bit, and the exercise actually
is probably a better vehicle to deal with the mental aspects, particularly for men.
Just in generally speaking … men don’t openly deal with cancer and a lot of
things as openly as women do and I think the exercise program just provides a
vehicle starting to talk about it, starting to think about it more yourself, getting
over that hump, getting past that worrisome element of it as well.
The men discussed together how this worked:
It brings you here [to counselling] in sort of, bit of an open state. Something
going around in your brain that makes you feel good.
And it actually helps to set the scene for here.
It brings us together, that we’re all working on this thing, all stretching, puffing,
panting, sweating and then after … you all come together.
It was not just the men who felt they needed the exercise to open their minds and
mouths. One woman said:
When we’re all together and we’re exercising, we’re not only exercising, we’re
also communicating, we’re also talking all the time … that is really important.
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These are the only people that I can talk about, my medication, my aches and
pains, these people are the only people that I can talk about that to.
They echoed the sentiment that doing the exercise before going to the counselling
helped relax them and prepared them to open up to each other:
If you’re not sharing anything else, you’re just getting in the room, you don’t
know each other, it’s hard to open up. But when you’re out there doing the
exercises, in between or on the bikes in the morning, you’re chatting. So you
feel more confident about expressing new thoughts because you learn to trust
people quicker, whereas if you just had to rely on the conversations here I think
it would take so much longer.
3.2.4.5 Changing perceptions of counselling.
At the initial assessment, many of the men asked if they could opt out of the
counselling sessions. They stated that they were drawn to the program for the free
exercise classes, but really had no interest in the psychological component. During the
feedback interviews, some men recalled their reluctance to participate due to a sense of
stigma surrounding mental health services. They thought that going to counselling made
them appear weak or less masculine. Other participants, both men and women,
described that they simply did not think they needed counselling. While some still held
that belief, others stated that participating in the program made them realise how much
they needed and wanted counselling. Overall, being together motivated everyone to
attend. One participant stated, ‘Even if I didn’t feel 100%, I thought I’ve gotta go, I
can’t bloody miss it. It was like a magnet drawing me here’.
Although more time was spent exercising, the SGP was equally important to the
participants. One subject commented, ‘just all exercise wouldn’t have been as
meaningful to me, or it wouldn’t have been as good without the counselling’. In contrast
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to most participants, one man described how the counselling, rather than the exercise,
drew him to the program. He wanted the counselling because he felt the mental
repercussions of prostate cancer had never before been dealt with.
Some of the benefits everyone derived from counselling were stress
management, coping skills and having the group support. Another benefit of the SGP
sessions stated by a participant was that ‘you probably come out of the whole
experience as a better person in a way because you can therefore cope with any other
things, similar things that might come up and just your outcome on life can change’.
While these could have been taught individually, ‘confronting the problems and
coping with people that are suffering the same thing is very beneficial’. For the group
dynamic, participating in counselling together made the group feel closer and better able
to understand each other. The act of sharing became important for the groups. One
woman described the counselling as ‘very helpful in sharing my journey with the group
and learning from their experiences too. It was also extremely beneficial to learn
techniques to manage stress, breathing and also in letting go of issues from the past’.
The participants did not want to share many details of what transpired in the
SGP sessions because they felt they were very private moments to be kept among
themselves. However, their commentary revealed more than enough:
I actually thought the forces, she [the counsellor] would ask or wouldn’t ask
something, and there would just be silence. And I actually thought that was
really powerful. ‘Cause it’s not that people were, well I don’t want to reveal
anything at the moment ‘cause it might embarrass me. Everyone was going
down deep within themselves and these two [the counsellors] gave a lot of life to
that, and I thought it was great.
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There was two times in meditation, one I was left with a hard rock, that’s what I
felt, and it was just a lot of stuff going on that I knew was there. Later on, we did
a meditation with a stupid thing, a little raisin, but it was brilliant. I actually felt
that rock melting. Things had changed.
Even the few men and women who did not feel the counselling was intrinsically
important or useful still felt that participating in the counselling was crucial to the
dynamic of the group. Therefore, the group aspect of the counselling made it important
to them.
3.2.4.6 The importance of participating in the intervention as a group.
In the end, the fellowship of the men or women who joined together to
collectively improve their health became the focus. Sharing experiences transcended
every aspect of the program. One woman described the group as ‘filling an enormous
hole for me’. A man shared that ‘this group’s the only place I’ve actually spoken, and
shared and talked with other guys who’ve been through and are going through the same
experience’. Cancer brought them together to the program, but the bonding they
experienced far exceeded the disease. Both men and women supported a participant’s
statement that ‘at times cancer can make you feel very alone, and suddenly you realise
there are others going through exactly the same thing’. That similarity and knowing that
everyone else faced the same problems and had many of the same fears made the
participants feel safer.
The real bonding came from participating, like any sports team, to see how
much they could achieve together. One participant stated, ‘I think it’s the group, and the
sense of camaraderie, and look we’re all in it together, so we’re all going to really go for
it’. As the patients always reiterated, the exercise alone was not enough—it was ‘being
with people who are in the same situation and listening to their stories as well’. The
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participants shared stories and jokes, which allowed them simultaneously to bond
together and cope. One man summarised the total importance of the group:
I tried a gym program before and didn’t last long. You didn’t feel like going and
you’d miss one—you miss one, you miss a couple. Whereas the fact that we
were here and it was a group, and I knew if I didn’t come I’d be missing out
being with you guys. That’s been enough for me, and that’s kept me coming,
even though I had three weeks off. The group aspect of doing, again as men,
doing something together physical builds that bond.
3.2.4.7 The importance of maintaining exercise behaviours.
Many participants who attended the final interview were concerned that once
they had graduated, they would backslide: ‘I’ve also noticed that since I’ve stopped the
exercise program, I’m eating quite naughty things’. The participants knew that, despite
all the fitness gains they had made in the two short months, ‘You can lose it much faster
than you can gain it’. The staff tried to prepare the graduates to continue exercising. For
some, this involved writing them an exercise routine to take to their local gym or to
complete at home. Others decided to take up yoga or tai chi lessons. They were
concerned that, without the regularly scheduled program, they would not continue
exercising, and thus they were sad to discontinue. As one man colourfully said:
It’s just like giving someone a piece of cake and you had a sample and think,
‘jeez, that’s delicious’, and then, ‘sorry, but you can’t have any more now’. All
we’ve done is have a taste, and it bloody tastes good, and now we want the
bloody slab of this cake, with our coffee.
However, the participants also understood that they needed to take responsibility
for their continued exercise, and could not just rely on the intervention:
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Ultimately, we’re responsible for ourselves and we are the ones that have to
maintain our own physical wellbeing. So it’s good that the ball has been passed
back to us and we’re now there with it, and we’ve got the tools you’ve given
us—the physical experience working in the gym and working in the pool. I feel
you’ve equipped us really well to establish a routine and, with gentle prodding
from our great friends, I think there’s no reason why we can’t continue.
3.3 Discussion
3.3.1 Feasibility and basic efficacy.
Feasibility was evident by the 80% participant attendance and retention rates.
The participants improved their cardiorespiratory fitness and lower body strength, with
cancer types improving at different rates. Additionally, only the breast cancer survivors
significantly improved their specific QOL scores. Although these results were limited
due to the small sample size and lack of control group to compare them against, they
warranted further comparisons between the cancer types in the main study.
3.3.2 Self-identity, prior experiences and overall benefits.
The prior experiences of the participants and their issues with self-identity were
what led them to participate in the intervention. Having not found appropriate help
elsewhere, either due to a lack of services or barriers to participation, the participants
felt that this intervention finally met their needs. Changes in self-identity, especially
concerning sexuality, are common in cancer survivors (Binkley et al., 2012; Ferrell et
al., 1997; Lintz et al., 2003). A positive outcome of this study was that the men felt that
the combination of exercise and SGP could help them regain feelings of masculinity. In
contrast, the women did not discuss improved feelings of sexuality. Instead, the women
tended to focus on feelings of quality and wellbeing in their lives. A common benefit to
all participants was creating a sense of greater control over their health.
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3.3.3 Importance of intervention components.
While many participants were initially reluctant to participate in the counselling,
most found it extremely beneficial and important to their experience. The counselling
helped them cope with their experiences through both the psychological exercises and
from having the opportunity to share their stories with the other participants. The
participants found the exercise beneficial not only for improving their fitness, but also
for helping them cope psychologically. The variety of exercises was described as
paramount for their motivation, learning and enjoyment.
Aside from any physiological improvements, the main significance of the
exercise portion in the context of the whole intervention was to facilitate a sense of
mutual aid, trust and group cohesion. Group bonding allowed for more open discussion
and sharing within the SGP sessions. The group became the most important aspect of
the program. Shared experience, both in the gym and through counselling, was the most
recurrent theme of the feedback sessions. The group became the main source of
enjoyment and motivation for the participants to attend the program.
3.3.4 Maintenance of benefits and behaviours.
The participants felt concerned that the completion of the intervention would
mean the end of their exercise routines. Research has shown that long-term physical
activity engagement is unlikely among cancer survivors, even after participating in a
structured intervention (Courneya et al., 2009; Ottenbacher et al., 2012). Further work is
needed to investigate helping cancer survivors make lifestyle changes to permanently
adopt physical activity.
3.4 Changes to Main Study
Based on the results of this pilot study, the following decisions were made in
regard to the methodology of the main phase of the research:
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1. The group exercise and SGP intervention were both feasible and acceptable
to both the men and women, and would be continued in the main phase of
the research.
2. Upon reviewing the results, some modifications were made to the initial
assessment battery:
a. A VO2peak cardiopulmonary exercise test, using indirect calorimetry,
replaced the submaximal treadmill walking test. As VO2peak was one of
the primary outcomes in the main study, a more sensitive and accurate
measure was required.
b. Based on the importance that participants—especially the men, in light
of their incontinence—placed on core stability, a measure of this
component of fitness was included.
c. Measures of upper body muscular endurance, upper and lower body
flexibility, fatigue and exercise motivation were added to address issues
of importance to the participants.
d. A follow-up assessment beyond the intervention was included to
determine the sustainability of the benefits gained because the
participants were concerned they would not continue exercising after the
intervention finished.
3. Based on the results of the pilot study, some changes were made to the
exercise intervention:
a. As the participants found the variety of exercises motivating and
beneficial, the exercise program in the main phase would include all the
various modes trialled in the pilot. However, to allow for the dose of
exercise to be determined, the exercise sessions would be more tightly
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structured. All participants in the main phase would undergo the same
exercise program, rather than having sessions prescribed specifically for
each group.
b. Behavioural constructs from the TTM were included to help facilitate
long-term exercise adoption because the participants stated that they
were afraid they would not continue exercising. Additionally, the
participants were provided with personalised exercise programs to follow
after the intervention finished in order to help promote long-term
exercise.
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Chapter 4: Main Study Methods
In the main phase of the project, breast and prostate cancer survivors were
recruited as samples of convenience, to either participate in a group exercise and SGP
intervention or to form a control group. The intervention participants were randomised
to two different exercise intensity groups. Details of the exercise prescriptions for each
group are provided below. The purpose of the study was to examine the maintenance of
responses to a short-term intervention. Physiological and psychological parameters were
compared between the two exercise intensity arms and the control group (C), before and
after eight weeks of either participating in the intervention or usual care. Further, the
sustainability of exercise behaviour, QOL, physiological parameters and psychological
parameters among the intervention groups were examined by repeating the assessments
four months after the intervention had finished.
4.1 Participant Recruitment
The participants were recruited from the Western Australian Hospital Benefits
Fund cancer patient registry, hospitals in Perth, the Breast Cancer Association of
Western Australia, and GPs in the Fremantle GP network. Recruitment took place
between April 2011 and April 2012 through flyer distribution, word of mouth and direct
mailings to Hospital Benefits Fund members who had been treated for breast or prostate
cancer. Interested people contacted the researcher, who developed a central list and
ensured these people met the eligibility criteria. The inclusion criteria were:

males and females aged 25 to 80 years

at Stage I, II or III breast or prostate cancer

completed the acute phase of treatment (participants still receiving adjuvant
hormone therapy were still eligible) within the previous five years
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
able to participate in exercise as determined by a PAR-Q, physician referral
and baseline screening

not currently involved in a structured exercise or counselling program.
The exclusion criteria were:

if a physician had identified a physical problem that would impede the
patient’s ability to complete the exercise program

metastatic breast or prostate cancer

beyond five years of treatment completion

unable to understand written or verbal English.
The presence of controlled comorbidities or diseases, such as lymphoedema or
type 2 diabetes, did not exclude a participant from participating as long as their
physician cleared them to participate in the exercise program. All the control
participants had to meet the same eligibility criteria as the intervention participants.
When a person who enquired about the program decided not to enrol in the intervention,
the researcher asked them to undergo the assessments and act as a control subject. In
February 2012, in order to boost recruitment numbers for the control group, a further set
of participants were contacted directly by mailings to Hospital Benefits Fund members.
These people were invited to participate in a set of free health and fitness evaluations 10
weeks apart.
4.2 Measures
4.2.1 Valdity and Reliability of Physiological Assessments
The available validity and reliability scores of the physiological assessments
used in the main study are presented in Table 8.
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Table 8
Summary of Validity and Reliability of Physiological Assessments
Assessment
Skinfolds
Shoulder
goniometry
Sit and Reach
Validity
The validity of the
skinfold method
compared to DEXA is
high (r = 0.75-0.89)
The validity of
goniometry compared
to digital inclinometry
was good, with
interclass correlation
coefficient > 0.85
Validity of the sit and
reach compared to 3D
kinematic measurement
was moderate to strong,
with a correlation
coefficient = 0.70
Cardiopulmonary The Moxus Modular
Exercise Test
metabolic system was
determined as valid for
determining VO2peak,
during a graded
cardiopulmonary
exercise test using a
Monark 828E cycle,
compared to a Douglas
bag, as evidenced by
non-significant
differences in VO2
calculation between the
methods.
Push Ups
The validity of the push
up test is good, as
evidenced by
correlations to maximal
repititions of a
submaximal (70% of
1RM for males and
40% of 1RM for
females) bench press
exercise of r =0.80-0.87
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Reliability
Intra-tester reliability as
determined through
coefficient = 0.99
Intra-rater reliability
classified as excellent
based upon interclass
correlation coefficient >
0.94
Author(s)
Erselcan,
Candan,
Saruhan, &
Ayca, 2000
Jackson,
Pollock, Graves,
& Mahar, 1988
Kolber &
Hanney, 2012
Intra-trial reliability was
excellent, with intraclass
correlation coefficient =
0.94-0.98
Bozic, Pazin,
Berjan, Planic,
& Cuk, 2010
Intra-test reliability was
determined as excellent as
evidenced by coefficient of
variations between tests of
1.2-5.3% for VO2.
Rosdahl,
Lindberg, Edin,
& Nilsson, 2013
good, with interclass
correlation coefficients =
0.96
Baumgartner,
Suhak, Chung,
& Hales, 2002
Negrete et al.,
2010
Assessment
Leg Press
Plank
Validity
The validity of the leg
press test was good
compared to isokinetic
strength testing using a
Cybex-II dynamometer,
as evidenced by r
values ranging from
0.72-0.77
No study of the validity
of the plank test was
found in adults. One
was found in children
age 8-12 years. In
children, the plank was
determined as valid, as
evidenced by all
subjects being able to
get a non-zero score, in
contrast to the partial
curl up test.
Reliability
Itra-trial reliability was
good, with correlation
coefficients of 0.88-0.89
Author(s)
Verdijk et al.,
2009
Hoeger et al.,
1990
good, as evidenced by the
coefficient = 0.83
Boyer et al.,
2013
4.2.2 Resting vitals and anthropometrics.
Vitals and body composition were measured after five minutes of rest. Resting
HR was measured using a Polar HR monitor (Kempele, Finland). Blood pressure was
measured by a 3M™ Littman stethoscope (Minnesota, USA) and sphygmomanometer
(ABN Healthcare Systems, Padalarang, Indonesia). Height was measured in centimetres
with a wall-mounted stadiometer, with participants standing with their shoes off and
head held in the Frankfort plane. Weight was measured in kilograms with an A&D
Weighing scale (California, USA) with shoes off. Body composition was determined by
a four-site skinfold measurement, using a Harpenden Skinfold Caliper HSK-B1 (British
Indicators, West Sussex, UK). The sites used were triceps, suprailiac, abdominal and
thigh. The four-site equation for determining BF% from these measures was developed
by Jackson and Pollock (1985). Skinfolds were chosen as the measure because they can
be taken quickly, are non-invasive and provide an inexpensive method for measuring
body composition. In breast cancer survivors, skinfolds have been shown to provide a
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more accurate estimate of body fat than comparably feasible methods, such as
bioelectrical impedance analyis, when compared to air displacement plethysmography
(Battaglini et al., 2011).
4.2.3 Flexibility.
Left and right shoulder ROM was assessed using goniometry (Box et al., 2002b;
McNeely et al., 2010). From the anatomical position, the participants performed
shoulder flexion, abduction and extension through their full ranges of motion, and the
movement from the anatomical position was recorded in degrees using a Jamar E-Z
Read goniometer (Sammons Preston Rolyan, Bolingbrook, IL, USA). For analyses,
degrees of motion from all three movements were summated to create a shoulder ROM
score. The participants also performed a general flexibility test using a sit and reach box
(ACSM, 2006). The participants were instructed to sit on the floor with their hips and
back flat against a wall and shoes off. The box was placed so that both feet were flat
against the inner wall, and the box was held in place. They were instructed to place their
hands flat on top of each other and stretch forward without lifting their knees up from
the ground, and push the slider as far as they could. Participants were given three
attempts, and the score was recorded as the furthest completed, in positive or negative
centimetres away from the foot line.
4.2.4 Cardiopulmonary fitness.
The participants completed a peak cardiopulmonary exercise test (CPET) (Jones
et al., 2008; Hermansen & Saltin, 1969; Hill & Lupton, 1923; Taylor, Buskirk &
Henschel, 1955) using a Monark Ergomedic 828E mechanically braked cycle ergometer
(Stockholm, Sweden) to determine VO2peak. The calibration procedures for the CPET
can be found in Appendix I. Oxygen uptake was analysed using the Moxus Modular
VO2 System (Naperville, USA) metabolic cart, with VO2 recorded every 15 seconds
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during the test. HR was monitored continuously throughout the test via a Polar HR
monitor, which was plugged into the metabolic system and recorded into the Moxus
software.
During the test, the participants were instructed to pedal at 60 revolutions per
minute, as displayed on the cycle ergometer. Verbal encouragement and feedback were
given to help keep them on pace. The participants warmed up for two minutes at an
initial power output of 30 watts (W), and each minute thereafter the power output
increased by 30 W. The participants were instructed to continue the test until they could
not maintain the cadence, and were encouraged to continue as long as they could. At
test completion, the participants continued to breathe through the mouthpiece while
pedalling at a power output of 30 W for at least one minute to cool down and to ensure
the software had captured their VO2peak.
4.2.5 Muscular strength and endurance.
The participants rested for five minutes after the CPET before performing a
range of muscular strength and endurance tests. Upper body endurance was assessed
through a maximal push-up test (ACSM, 2006). Push-ups were performed to a
metronome set at 60 beats per minute, with one motion (either down or up) completed
on each beat. Following the test protocols, the men were instructed to perform their
push-ups from their toes, while the women performed them from their knees. The test
ended when the participant could not perform any more push-ups, could not keep up
with the rhythm, or chose to stop. After the push-up test, the participants were given
two minutes of rest.
Their core endurance was assessed by a timed plank test (National Academy of
Sports Medicine, 2004). The participants were instructed to hold the plank position,
seen in Figure 1, for as long as possible. The time held was recorded to the nearest tenth
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of a second. Their lower body strength was assessed through a 1RM leg press test
(ACSM, 2006) using a SportsArt A956 horizontal leg press machine (Tainan City,
Taiwan).
Figure 1. Position for plank exercise.
4.2.6 Questionnaires.
1. Cancer-specific QOL was measured by using questionnaires from the
Functional Assessment of Chronis Illness Therapy (FACIT) system, using
the FACT-G and respective additional concern subscales to form the FACTB (Brady et al., 1997; Cella et al., 1993) and FACT-P (Esper et al., 1997;
Cella et al., 1993).
2. Exercise motivation was measured by the BREQ-2 because this
questionnaire can discriminate between autonomous and extrinsic motivation
(Markland & Tobin, 2004).
3. Fatigue was assessed by the Piper Fatigue Scale (PFS) (Piper et al., 1998).
4. Physical activity levels were measured by the International Physical Activity
Questionnaire (IPAQ)—Short Form, using a seven-day recall (Craig et al.,
2003).
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5. A demographics questionnaire created for the purposes of this research and
approved for use by the Human Research Ethics Committee was used
(Appendix B).
Copies of all questionnaires are provided in Appendix C. A summary of each
questionnaire, along with their validity, reliability and clinical significance, can be seen
in Table 9.
At each assessment, all questionnaires were reviewed by the researcher for
completeness and to check for any potential incorrect answers. A common mistake
made on the FACIT system questionnaires arose in the emotional wellbeing subscale.
For most of the questions, a ‘0’ indicated the most positive feeling. For example,
answering ‘0’ to ‘I feel sad’ indicated that they did not feel sad. Unfortunately, many
people fell into a pattern of marking all the questions in that subscale ‘0’, including ‘I
am satisfied with how I am coping with my illness’. In cases where it appeared that the
participant had fallen into a pattern, they were asked to confirm their answer for their
coping satisfaction. Aside from these discrepancies, the IPAQ scores were checked to
try to limit the error in reported physical activity levels. In cases where participants
reported what seemed to be more physical activity than they were likely to perform,
they were asked about their activities to confirm their answers on the IPAQ. Where
mistakes were discovered, answers were changed accordingly.
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Table 9
Questionnaire Summary, Validity, Reliability and Clinically Meaningful Change
Questionnaire
FACT-B and P to
measure QOL
Summary
Validity
 Items graded on five-point Likert scale.
 Items summated to create subscale score.
 Subscales: physical wellbeing (PWB), social
wellbeing (SWB), emotional wellbeing (EWB),
functional wellbeing (FWB), additional concerns
(AC).
 PWB + SWB + EWB + FWB = FACT-G score;
FACT-G + AC = FACT-B/P total score.
Internal consistency (alpha
= 0.87–0.89); discrimination
(p < 0.05); sensitivity to
change over time (p < 0.05);
sensitivity to change (p =
0.006)
 Items graded on five-point Likert scale.
 Item scores averaged to create subscale scores, which
were: amotivation, external regulation, introjected
regulation, identified regulation and intrinsic
regulation.
 An overall score, the RAI, was calculated by
multiplying each subscale by a coefficient and
summing them. The creators warn that looking at the
RAI alone without examining the subscales separately
may not provide valid reflections of selfdetermination. The coefficients were: amotivation -3;
external regulation -2; introjected regulation -1;
identified regulation +2; intrinsic regulation +3.
Goodness of fit (p < 0.001);
internal consistency (r >
0.70); factorial validity (p <
0.001)
Reliability
Test-retest (r =
0.85)
Clinically meaningful
change
FACT-G: 3–7 points
FACT-B and P: 6–10 points
(Brady et al., 1997)
(Cella, Nichol, Eton, Nelson
& Mulani, 2009; McNeely
et al., 2006; Webster, Cella
& Yost, 2003)
Subscale test-retest
reliability (r =
0.76–0.90
A significant difference on
any subscale may be as
small as 0.2 points, with
autonomous areas perhaps
closer to 1.0; overall RAI
difference may range from
5–8 points
(Brady et al., 1997; Esper et
al., 1997)
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BREQ-2 to measure
exercise motivation
(Markland & Tobin, 2004;
Mullan, Markland &
Ingledew, 1997; Wilson,
Rodgers & Fraser, 2002)
(Mullan et al.,
1997; Wilson et al.,
2002)
(Milne et al., 2008a; Milne
et al., 2008c)
Questionnaire
PFS to measure
fatigue
Summary
 Items graded on a 10-point Likert scale.
 Item scores averaged to create subscale scores.
 Subscales included behavioural/severity, affective
meaning, sensor and cognitive/mood.
 Subscale scores were averaged to create overall
fatigue score.
Validity
Reliability
Criterion validity: Pearson’s
correlation with
Multidimensional Fatigue
Inventory was (r = 0.84) and
with Rotterdam Symptom
Checklist was (r = 0.74)
Test-retest
reliability (r >
0.80); internal
consistency by
Cronbach’s alpha >
0.93
(Dagnelie et al., 2006)
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IPAQ—Short Form
with seven-day recall
to measure physical
activity levels
 Participants recalled frequency and duration in the last
week of performing vigorous and moderate physical
activity and walking for more than 10 minutes.
 Vigorous physical activity was assigned an MET level
of eight, moderate physical activity was assigned an
MET level of four, and walking was assigned an MET
level of 3.3.
 MET hours per week were calculated by multiplying
days/week of each activity, hours/day of each activity,
and assigned MET level, and summing all scores.
Mean correlation between
IPAQ results and objective
measure of physical activity,
as reported by systematic
review (r = 0.29); criterion
validity (p = 0.30)
(Piper et al., 1998)
(Dagnelie et al.,
2006; Piper et
al., 1998)
Test-retest
reliability
Spearman’s
correlation (p =
0.80)
(Craig et al., 2003)
(Craig et al., 2003; Lee,
Macfarlane, Lam & Stewart,
2011b)
Clinically meaningful
change
Three points on the total
score or any subscale would
be a full reduction in a
severity level
NA
4.2.7 Aerobic compliance and workload.
Exercise session HRs were monitored and recorded continuously using the
Team2 Polar HR monitoring system (Kempele, Finland). HR data were recorded in real
time. The Team2 Polar software allows markers to be placed in the exercise sessions to
indicate times that a specific activity commenced and ended. This function was used to
indicate when the participants were performing aerobic, resistance or flexibility
exercises. This software can also show the average HR during a given segment of
interest. In this case, average HRs during aerobic exercise were selected and recorded in
a data set for each participant. For every exercise session, aerobic compliance was
calculated as: (mean HR performed during aerobic exercise) / (target HR for that
session). This was done to derive the percentage of their target HR that each participant
performed during their aerobic exercise (Ettinger et al., 1997). The aerobic workload
was determined in both absolute and relative terms. The absolute workload was the
mean HR achieved during an aerobic portion of each exercise session. The relative
workload was calculated as: (aerobic compliance) ∙ (targeted % VO2peak) (Bradfield,
1971).
4.2.8 Resistance training workload.
The daily resistance training workload was calculated as the sum of (kg lifted) ×
(repetitions performed) for all exercises (Fleck, 2004). For the calculation, body weight
exercises, such as push-ups, were counted as one kilogram lifted, and repetitions of
timed exercises, such as the plank pose, were counted as seconds held.
4.2.9 Rating of perceived exertion.
The RPE scale used in this study was the category scale with ratio properties
from one to 10 (CR-10) (Borg, 1982). The CR-10 is a more accurate RPE scale during
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resistance training and for rating overall session RPE than is the original six to 20 scale
(Borg, 1970; Borg, Hassmen & Lagerstrom, 1987; Borg & Kaijser, 2006).
4.2.10 Safety and adherence.
Any adverse events, including injury or lymphoedema, were recorded in the
daily training logs by the researcher in order to assess safety. The safety plan procedure
for an injury was to provide basic first aid treatment and assess if the participant needed
to see a doctor or physiotherapist. If this recommendation was made, participants were
asked to make an appointment with their regular physiotherapist. For women who were
suffering lymphoedema, they were instructed to wear compression sleeves during
exercise sessions and to follow any recommendations or instructions provided by their
physiotherapist. Women who felt their lymphoedema may be worsening during the
program were referred back to their lymphoedema-specialist physiotherapist. Any
further instructions or limitations provided by their physiotherapist were followed.The
exercise sessions are presented in Appendix G, with an example of the sheet used for
the training log presented in Appendix F. Attendance to the exercise and SGP sessions
were recorded separately as a percentage of the sessions attended.
4.3 Group Exercise and SGP Intervention
Intervention courses were offered approximately every 12 weeks from June
2011 to April 2012. The breast and prostate cancer survivors were not intermixed in the
intervention, but participated in separate groups. The segregation of the sexes was done
in accordance with the recommendation from the counselling department that the SGP
sessions should be of only one gender. Additionally, the bonding of the participants in
the pilot study during the exercise session helped facilitate the counselling; the
participants had commented that one of the parts to that bond was “us men” or “us
women” working together to get through the workouts. A minimum of six participants
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of the same gender had to register their interest, be confirmed eligible and undergo
baseline assessments before an intervention group commenced. A maximum of 10
participants were allowed in each group; thus, when more than 10 (but at least 12, to fit
the minimum of six per group) participants enrolled, two groups of the same gender
were created. When multiple groups for the same gender were run simultaneously, the
participants were allowed to pick the starting time they preferred. Groups did not meet
simultaneously, but were scheduled throughout the day. For example, at one point, there
were two prostate cancer groups—one meeting at 7.45 am and the other at 9.00 am—
and two breast cancer groups—one meeting at 10.30 am and the other at 5.30 pm.
4.3.1 Exercise intensity assignment.
After an intervention group was formed and all participants had completed the
baseline assessments, the group was randomly allocated an exercise intensity
prescription. The random number generator in Microsoft Excel (Microsoft, Redmond,
USA) was used to determine group assignment: even numbers were allocated to the LIG
and odd numbers were allocated to the HIG. The members assigned to each intensity
were not intermixed in the intervention groups. The participants in the exercise
intervention groups were blinded to the existence of treatment groups and their group
allocation in order to minimise contamination of behaviours and target intensity.
4.3.2 Program design and behaviour change and sustainability.
The TTM was used to positively influence patient adherence and motivation to
the exercise program (ACSM, 2006; Burbank et al., 2002; Guillot, Kilpatrick, Hebert &
Hollander, 2004; Hutchison et al., 2009; Kim, 2007; Nigg & Riebe, 2002; Prochaska &
Marcus, 1993). The goal of the study was to help participants enter the maintenance
stage—that is, to help them meet the PAG for at least six months (Kim, 2007;
Prochaska & Marcus, 1993). Consequently, three behavioural processes were employed.
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These processes were counter-conditioning (such as going for a walk with friends,
rather than sitting and drinking tea), helping relationships (such as finding a friend to
exercise with) and reinforcement management (such as establishing a fitness goal and
corresponding reward) (Burbank et al., 2002; Kim, 2007; Loprinzi et al., 2012).
The behavioural change strategies were delivered at the end of each exercise
session for approximately five minutes. The participants were given information about
these strategies and were asked to share how they would accomplish them. The
researcher facilitated a short discussion until everyone had the opportunity to contribute.
The strategies focused on creating a plan to continue exercising after the intervention
had finished, and sought ways to incorporate more physical activity into the
participants’ daily lives. Some questions asked how the participants planned to continue
their exercise. Common answers included joining a private gym, joining another
exercise group or performing exercise at home. At the end of the program, the
researcher helped each participant to fulfil these goals by giving them information on
exercise groups or gyms near them and by providing a tailored exercise program for
them to follow.
4.3.3 Exercise prescription.
The exercise sessions lasted approximately one hour and were held every
Monday, Wednesday and Friday for eight weeks. The exercise prescription followed the
guidelines for intensity, volume and progression, as outlined by the ACSM (ACSM,
2009; ACSM et al., 2009; Garber et al., 2011). A full description of each exercise
session can be found in Appendix G. The exercise sessions were tracked and recorded
in exercise logs (Appendix F). A sample exercise session for the HIG is presented in
Table 10. As can be seen, the aerobic, resistance and flexibility exercises were
interspersed throughout the session.
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Table 10
Sample Exercise Session
Exercise
Preferred cardio machine
Stretch
Front squat
Bicycle
Push-ups
Cross trainer
Russian twist
Rower
Lat pull downs
Arm crank
Plank
Treadmill
Volume
5 minutes
5 minutes
2 sets x 8 repetitions
3 minutes
3 minutes
3 minutes
3 minutes
3 sets x 15 seconds
3 minutes
4.3.3.1 Aerobic exercise prescription.
The HIG was prescribed to perform aerobic exercise at 75 to 80% VO2peak
because this is considered a high aerobic intensity, but is still underneath the anaerobic
threshold (Garber et al., 2011; Norton et al., 2010). As most of the aerobic exercise
bouts were performed for 10 minutes or less, this was considered a feasible combination
of intensity and duration of aerobic exercise (Norton et al., 2010; Quist et al, 2006). The
LIG was prescribed to exercise at 60 to 65% VO2peak because this is the minimum
intensity recommended by the ACSM for older adults to improve their VO2peak
(ACSM et al., 2009; Jones et al., 2010a).
To monitor aerobic exercise intensity during the exercise sessions, target HRs
were determined as the HR achieved at the prescribed VO2 during the CPET (Bradfield,
1971). The prescribed VO2 for each intensity group and the corresponding mean HRs
are shown in Table 11. To match energy expenditure between the intensity groups and
to make the groups isocaloric, the HIG performed 80% of the minutes of aerobic
exercise compared to the LIG. This percentage of time was chosen because it was the
ratio of the initial aerobic exercise intensities between the groups (60% / 75% = 0.80)
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(O’Donovan et al., 2005; Rognmo et al., 2004) For example, if the LIG performed 10
minutes of aerobic exercise, the HIG performed eight minutes.
Table 11
Prescribed Aerobic Exercise Intensity and Progression in Relative and Absolute
Measures
VO2
Group
LIG
HIG
n
44
40
Initial
Progressed
60% of VO2peak
75% of VO2peak
65% of VO2peak
80% of VO2peak
Initial BPM
M (SD)
109.5 (15.6)
120.3 (12.1)
Target HR
Progressed BPM
M (SD)
115.4 (15.4)
127.4 (14.9)
Throughout the program, every participant was assigned a specific HR monitor
that they wore every session. Each individual was advised of their initial target HR on
the first day. The participants exercised at the initial target for the first four weeks to
allow for sufficient adaptation (ACSM, 2009; ACSM et al., 2009; Garber et al., 2011).
On the Monday of the fifth week of the intervention, the participants were told their
progressed HR target. The participants were progressed to ensure continued adaptation
and improvement (ACSM, 2009; ACSM et al., 2009; Garber et al., 2011). The data
from the Team2 Polar system were used to check that the participants adhered to the
target intensities. The participants were encouraged throughout the aerobic exercise
sessions by the researcher to maintain their target HR. The importance of staying at
their target HR to ensure the validity of the research was emphasised to the participants.
They were advised that their HR was based on their CPET, and that prior research had
deemed that level as optimal for them.
4.3.3.2 Resistance exercise prescription.
The resistance intensities were prescribed according to the principles of the
ACSM position stand on resistance training (ACSM, 2009). The leg press was used to
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test for 1RM, and, subsequently, the resistance training was based on the progression of
the leg press exercise. For the LIG, the leg press was prescribed initially at 50% 1RM
and progressed to 65% 1RM. For the HIG, the leg press started at 65% and progressed
to 80% 1RM (ACSM, 2009). All other exercises using external weight were prescribed
initially as a percentage of body weight, with the progression of these being based on
the ratios from the leg press progressions (15% increases). The percentage of body
weight calculations was based on the work and recommendations of Schneider et al.
(2003), and are included in Appendix H. As the body weight method was less accurate
than the 1RM testing, the loads were adjusted based on the participant’s RPE. The LIG
was targeted to an RPE of two to four, while the HIG was targeted to an RPE of five to
seven (ACSM, 2006; Borg, 1982). In each session, the participants were asked about the
perceived difficulty of the resistance exercises, and the weights were adjusted
accordingly. When they reported an RPE above their target, they were given a lighter
weight; conversely, if they reported an RPE below their target, they were given a
heavier weight. The specific weight was at the discretion of the researcher. In addition,
the participants were asked to provide a session RPE to help adjust their workload and
keep them within their assigned level of intensity. During the exercise sessions, the
resistance exercise prescription was written on a whiteboard. The participants tracked
their sets and changes in weights on the whiteboard, and any changes were recorded in
the official training logs (Appendix F). The volume of resistance training and exercise
selection were identical between the intensity groups, with only the prescribed intensity
(the number of kilograms lifted) differing.
4.3.4 Supportive group psychotherapy.
The SGP was held once each week for 90 minutes. The exact day for the SGP
changed with each course, depending on counsellor availability. The sessions occurred
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immediately before or after the exercise session for that day, and were led by two
qualified counsellors. Only one group (a women’s HIG) had the counselling session
before exercise, due to counsellor’s schedules. While no formal analysis was performed,
the professional opinion of the counsellors and researcher was that the order of exercise
and counselling did not impact the women’s participation. A combination of individual
expression, group discussion, teaching and problem solving was used by both the
counsellors and the participants (Breitbart, 2002; Breitbart et al., 2010; Cain et al.,
1986). The weekly topics were: 1) exploring life stories, 2) implications of living with
cancer, 3) coping with stress, 4) mindfulness and feeling anxious, 5) relationships and
support, 6) self-identity, 7) hope, and 8) moving forward.
4.4 Usual Care
The control participants were instructed to continue their normal routine during
the eight weeks between the baseline and post-intervention assessments.
4.5 Procedures
All assessments for a given participant were conducted at the same time of day.
The participants were asked to come to all assessments after having fasted for at least
two hours, not smoked for three hours and not exercised earlier that day. The baseline
assessment was undertaken over two days, 48 to 72 hours apart. On day one, resting
vitals, anthropometrics, flexibility and cardiopulmonary fitness were measured. The
participants were given the FACT-B or FACT-P, BREQ-2, PFS and IPAQ and were
asked to complete and return these on the second assessment day. On day two, the
CPET was repeated, and muscular strength and endurance were assessed.
The control group was assessed in two ways. Most control participants (n = 19
prostate cancer survivors and 23 breast cancer survivors) were assessed following the
same procedures and timeline as the intervention participants. In order to boost
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numbers, a further set of control participants (n = 16 prostate cancer survivors and 17
breast cancer survivors) were recruited and asked to complete all baseline assessments
in one day. This meant they did not repeat the CPET. It was not possible to determine if
the results for this assessment would differ as a consequence. Performing all tests in one
day had no effect on the other assessments.
The intervention and usual care lasted for eight weeks. The exercise sessions are
fully described in Appendix G and summarised in Table 12. In week 10, the participants
were reassessed on resting vitals, anthropometrics, flexibility, cardiopulmonary fitness
and muscular strength and endurance. The intervention participants were given the
FACT-B or FACT-P, BREQ-2 and PFS on their last day of exercise in week nine to
complete and bring to their final assessment. The control participants completed the
questionnaires upon arrival. The IPAQ was not issued at post-intervention because the
research focused on whether the participants would make a significant and lasting
change in physical activity levels compared to their baseline activity, regardless of what
they were performing during the intervention (that is, when not in a formal
intervention).
A follow-up assessment was conducted four months post-intervention for the
intervention participants. Since the purpose of the follow-up assessment was to
determine the sustainability of changes made through participating in the intervention,
the control participants were not included. The questionnaires (FACT-B or FACT-P,
BREQ-2, PFS and IPAQ) were posted to the participants in advance of their follow-up
assessment, along with their appointment reminder. On this final iteration of the IPAQ,
the following question was added:
Please detail what exercise activities (e.g. golf, strength training, walking the dog) you
have participated in during the last week. Also please indicate any circumstances
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Table 12
Program Schedule
Week
1
2
Monday
First day of baseline assessment



3–5
Introduction to Team2 Polar HR monitors.
20-minute walk outside to practise HR
monitoring.
20-minute exercise routine that included
balance, flexibility and resistance training,
using only a park bench.
Friday
Second day of baseline assessment



Introduction to cardio machines.
HR monitor use reviewed, and participants
practised staying in their training zones on each
piece of equipment.
Introduction to core stability exercise
technique.


Introduction to cardio boxing.
Introduction to resistance training.
Every exercise session was different, but they all followed the pattern outlined below. The times displayed are for the LIG group. The HIG group
performed 80% of these times for aerobic exercise. The time in each activity was not necessarily continuous. See Appendix G.
125
25 min. aerobic, 25 min. resistance and 10 min.
flexibility training.
6
Wednesday
Participants repeated the sessions from week two, but with progressed intensities. They used this week to perform familiar exercises and learn to work in
their new training zones. The LIG progressed their aerobic work to the HR that corresponded to 65% of their VO 2peak, and the HIG progressed their
aerobic work to the HR that corresponded to 80% of their VO 2peak.
7–9
Participants repeated the exercise sessions from weeks three to five with the progressed intensities.
10
Post-intervention assessment.
24
Follow-up assessment
(e.g. work, illness, holiday) that may have impaired your ability to exercise in
the last week.
Any additional pertinent information offered during the conversation was added to the
notes. The participants were assessed on resting vitals, anthropometrics, flexibility,
cardiopulmonary fitness and muscular strength and endurance.
4.6 Ethics
This research project received ethical clearance from the University of Notre
Dame Australia Human Research Ethics Committee (study #011024F). All participants
were provided with an information sheet and all provided written informed consent
before enrolment in this program (Appendix A). This study was registered with the
Australian New Zealand Clinical Trials Registry (ACTRN12611000436976) and the
Australian Cancer Trials registry.
4.7 Data Analysis
4.7.1 Sample size.
The sample size calculation for this study used the data reported by Courneya et
al. (2003b), which compared changes in VO2peak in a control group (n = 28) and an
aerobic exercise group (n = 25) of breast cancer survivors. The difference in the
response was normally distributed, with a standard deviation of 3.8. If the true
difference in VO2peak between the experimental and control means was 3.1 ml/kg/min,
23 experimental participants and 26 control participants needed to be studied to be able
to reject the null hypothesis that this response difference was zero with probability
(power) 0.8. The Type I error probability associated with the null hypothesis is 0.05.
This calculation was completed using the Power and Sample Size Program (Dupont &
Plummer, 1990). To adjust for not having matched pairs and possible drop-outs or non-
126
compliance, 25 participants with each cancer type were targeted to be recruited into
each group (HIG, LIG and C).
4.7.2 Statistical analyses.
All statistical analyses were completed using SPSS Version 20 (IBM, Armonk,
USA). Statistical significance was set a priori at p < 0.05. The statistical methods used
to answer each research question are presented below. Descriptive statistics were
generated for demographic and treatment variables, either as means with standard
deviations or as the number of participants with percentage of participants. The
demographic and treatment variables were compared between the groups, separated by
cancer type. Age and months post-treatment were also compared between the cancer
types. Continuous variables were analysed with univariate ANOVAs, while categorical
variables were analysed with Pearson chi-square tests.
4.7.2.1 Research questions.
1. Is a group exercise and SGP intervention feasible and acceptable to breast
and prostate cancer survivors?
The first research question was addressed in the pilot study, as described in
Chapter 3, by using a mixed-methods approach of interpretative phenomenological and
statistical analyses. The intervention was feasible and acceptable in both populations.
The initial results indicated that further comparisons between the cancer types were
warranted.
2. Are breast and prostate cancer survivors able to adhere to and comply with
an exercise program at an intensity of 75 to 80% VO2peak and 65 to 80%
1RM?
Adherence was measured as the percentage of exercise and SGP sessions
attended. Compliance was measured as the percentage of target aerobic intensity
127
achieved and target resistance workload achieved. Adherence and compliance were
compared between groups and cancer types by univariate ANOVAs. Additionally, any
adverse events were noted in the training logs.
3. Are there differences in the physiological and psychological responses
between cancer survivors participating in an exercise program at 60 to 65%
VO2peak and 50 to 65% 1RM, 75 to 80% VO2peak and 65 to 80% 1RM, or
usual care?
To determine if there were differences in the responses of the groups (LIG, HIG
and C) or the cancer types to the intervention, change (delta) scores were calculated for
each participant as post-intervention minus baseline. Change scores were compared via
intention to treat analysis of covariance (ANCOVA), using age and months posttreatment as covariates for all outcomes, as these were the two factors significantly
different between groups. Post-hoc comparisons between groups were conducted using
adjusted Bonferonni tests.
4. Are there differences in the sustainability of physiological and psychological
parameters at follow up between the breast and prostate cancer survivors
who completed the program exercising at a higher intensity, compared to
those who exercised at a lower intensity?
Due to differing samples participating in the post-intervention and follow-up
assessments, separate statistical analyses were performed to compare changes between
the assessment points (between the baseline and post-intervention and between the postintervention and follow up). To compare if there were differences in the changes of the
intervention groups (LIG and HIG) or the cancer types at the follow-up assessment,
change scores for each participant were calculated as follow up minus post-intervention,
and analysed via ANCOVAs again using age and months post-treatment as covariates
128
for all outcomes. Post-hoc comparisons between groups were conducted using adjusted
Bonferonni tests.
program adherence between breast and prostate cancer survivors to the same
group exercise and SGP intervention?
To account for the interaction between cancer type and group assignment, both
of these independent variables were used simultaneously in the ANCOVAs that tested
the change in outcomes between assessment periods. While the results were generated
simultaneously, the main effects for comparing the cancer types and the interaction
effect between cancer type and group assignment are presented separately.
6. Are there differences in physical activity levels four months after a shortterm intervention between breast and prostate cancer survivors who
completed the program exercising at a higher intensity compared to those
who exercised at a lower intensity?
Physical activity was determined using the IPAQ, which has been shown to
overestimate physical activity levels (Lee et al., 2011b). Therefore, two analyses of the
IPAQ scores were run—one including and one excluding outliers—to compare the
physical activity levels between groups and cancer types at baseline and again at follow
up. Outliers were identified as being more than three standard deviations from the mean
at baseline and follow up on total MET hours per week. Any participant identified as an
outlier had all their data from the IPAQ removed from the second analysis. Total MET
hours per week were compared by univariate ANOVAs, using group and cancer type as
the between-subjects factors. Additionally, univariate ANOVAs were used to compare
hours per week of moderate and vigorous intensity physical activity between groups and
cancer types. At the follow-up assessment, the participants reported why they had
129
decreased their physical activity and what activities they had performed during the
sustainability period. These notes were coded to create non-parametric variables to
determine how frequently answers were given. All non-parametric variables were
compared between groups (LIG versus HIG) using Pearson chi-square tests.
130
Chapter 5: Results
In this chapter, the results of the main study are presented. First, the sample
characteristics are described and then the statistical results in order of the research
questions are presented.
5.1 Participant Recruitment and Retention
Of 222 people interested in participating, 29 (13%) were ineligible, mostly due
to having another cancer or a metastatic cancer or still undergoing treatment. Of 193
eligible participants, 159 (82%) enrolled in either the intervention or control groups,
with 84 (44%) enrolling in the intervention and 75 (69%) participating as controls as
samples of convenience (see Figure 2 for the participant flow diagram and more details
about recruitment).
5.1.1 Intervention participants.
The most frequent reasons for not participating in the intervention were work
commitments and that the timing did not suit. Four participants (two men and two
women) dropped out of the intervention, resulting in a 95% retention rate. The reasons
for dropping out included moving interstate and cancer reoccurrence. Of the 80 people
who completed the intervention, 64 (80%) returned for the follow-up assessment, with
another eight completing the questionnaires, but not the physiological assessments. Of
these eight people, four were assigned to the LIG and four to the HIG. The reasons for
not participating in the follow-up assessment included surgery, extended holiday during
the follow-up period, and personal issues. The final sample size of 72 participants
provided adequate statistical power (at least 25 in both the LIG and HIG). See Figure 2
for details on how many breast and prostate cancer survivors were retained in each
group at follow up.
131
5.1.2 Control participants.
Some eligible participants (n = 19 men, 23 women) who declined to enrol in the
intervention consented to act as control subjects. To boost recruitment of controls, an
additional 16 men and 17 women were specifically recruited. Ten men and 17 women
did not return for the post-intervention assessment, resulting in 64% retention of
controls. None of these participants provided a reason for missing the assessment. The
control participants were not followed up four months post-intervention because the
purpose of the four-month follow up was to assess the sustainability of the changes
achieved during the intervention.
132
Figure 2. Participant recruitment flow diagram.
133
5.2 Participant Characteristics
The treatment and demographic variables of the participants are presented in
Tables 13 to 15. The numbers vary for some demographic characteristics due to missing
data. Although the breast cancer survivors tended to be further past treatment
completion, there were no significant differences between cancer types on months posttreatment (Table 13). The prostate cancer survivors were significantly older than the
breast cancer survivors. This difference was expected because the typical age of
diagnosis of prostate cancer is 8.1 years later than for breast cancer (Australian Institute
of Health and Welfare & Australasian Association of Cancer Registries, 2010).
Table 13
Comparison of Cancer Types for Age and Months Post-treatment
Prostate cancer
Breast cancer
Cancer type
survivors
survivors
differences
(n = 87)
(n = 72)
M (SD)
M (SD)
p
Age (years)
65.8 (6.6)
56.8 (9.6)
< 0.001
12.6 (13.0)
16.7 (14.8)
0.07
Median months post-treatmenta
8
14
0.06
Note: significant cancer type differences in bold. a Median months post-treatment compared by
Independent Samples Kruskal-Wallis Test.
Measure
There were no differences in age between the exercise groups within each cancer
type (Tables 14 and 15). Among the prostate cancer survivors, there were no significant
differences between exercise groups for the majority of demographic or treatment
variables (Table 14). However, the men who participated in the intervention had a
median of 5 months post treatment completion, while the controls had a median of 13
months (p = 0.013). The prostate cancer survivors were predominantly at Stage II or III
and had only undergone a prostatectomy. Among the breast cancer survivors, there were
no significant differences on treatment characteristics (Table 15). The breast cancer
134
survivors were mostly at Stage I or II; had undergone surgery, chemotherapy, and
radiation therapy; and were on an adjuvant hormone therapy during the study. More
HIG participants were still working compared to the other groups. Among the breast
cancer survivors, there were no other significant differences in the demographic
variables. Overall, the participants from both cancer types were married, had completed
some tertiary education, were not currently working, and had private health insurance.
The descriptive statistics for the baseline outcome measures for each cancer type within
group assignment are reported in Tables 16 to 19.
135
Table 14
Prostate Cancer Survivors’ Treatment and Demographic Characteristics
Measure
Age (years)
Median months posttreatmenta
LIG
(n = 25)
M (SD)
65.0 (6.3)
9.0 (10.6)
HIG
(n = 27)
M (SD)
65.3 (7.0)
11.2 (15.1)
C
(n = 36)
M (SD)
66.9 (6.6)
16.5 (12.1)
5
5
13
n (%)
5 (20)
17 (68)
3 (12)
23 (92)
2 (8)
n (%)
3 (11)
17 (63)
7 (26)
22 (82)
5 (19)
n (%)
1 (3)
19 (59)
12 (38)
27 (82)
10 (30)
Group difference
p
0.49
0.07
0.013
χ2
Stage I
Stage II
0.12
Stage III
Prostatectomy
0.48
External radiation
0.11
Brachytherapy
Low dose
0
3 (11)
3 (9)
0.35
High dose
0
0
1 (3)
ADT
3 (12)
3 (11)
7 (21)
0.48
Marital status
Single
2 (8)
2 (7)
7 (8)
Married
21 (84)
22 (82)
72 (84)
0.26
Divorced
0
3 (11)
5 (6)
Widowed
2 (8)
0
2 (2)
Highest level of education
Year 10
5 (20)
4 (15)
5 (14)
Year 12
4 (16)
2 (7)
5 (14)
Technical school
5 (20)
6 (22)
11 (31)
0.94
Undergraduate degree
4 (16)
5 (19)
4 (11)
Postgraduate degree
5 (20)
9 (33)
8 (23)
Other
2 (8)
1 (4)
2 (6)
Not working
15 (60)
16 (59)
21 (60)
Working 1–19 hours
2 (8)
1 (4)
2 (6)
0.84
3 (12)
4 (15)
8 (23)
Working 40+ hours
5 (20)
6 (22)
4 (11)
Retired
17 (68)
15 (56)
20 (57)
0.61
Annual household income
level
0
0
1 (3)
< $6,000
3 (14)
6 (22)
7 (22)
$6,000–35,000
0.62
7 (32)
7 (26)
13 (41)
$35,000–80,000
10 (46)
13 (48)
8 (25)
$80,000–180,000
2 (9)
1 (4)
3 (9)
> $180,000
Had private health insurance
23 (92)
27 (100)
34 (100)
0.08
Note: a Median months post-treatment compared by Independent Samples Kruskal-Wallis Test.
Significant (p < 0.05) group differences in bold.
136
Table 15
Breast Cancer Survivors’ Treatment and Demographic Variables
Measure
Age (years)
Median months post-treatmenta
LIG
(n = 19)
M (SD)
58.2 (9.6)
14.4 (11.6)
9
n (%)
9 (47)
6 (32)
4 (21)
12 (63)
7 (37)
0
12 (63)
17 (90)
HIG
(n = 13)
M (SD)
53.5 (9.0)
15.1 (17.4)
12
n (%)
6 (46)
7 (54)
0
6 (46)
7 (54)
0
10 (77)
7 (54)
C
(n = 40)
M (SD)
57.2 (9.8)
18.4 (15.4)
15
n (%)
15 (42)
18 (50)
3 (8)
15 (39)
23 (59)
1 (3)
26 (67)
27 (71)
Group difference
p
0.37
0.57
0.56
χ2
Stage I
Stage II
0.30
Stage III
Lumpectomy
Mastectomy
0.45
Both
Chemotherapy
0.70
Radiation therapy
0.08
Adjuvant hormone therapy
Tamoxifen
6 (33)
8 (62)
15 (40)
0.23
Aromatase inhibitor
6 (33)
2 (15)
17 (45)
Herceptin
3 (16)
1 (8)
5 (13)
0.80
Marital status
Single
1 (5)
1 (8)
2 (5)
Married
15 (79)
10 (77)
28 (72)
0.95
Divorced
3 (16)
2 (15)
9 (23)
Widowed
0
0
0
Highest level of education
Year 10
3 (16)
0
5 (13)
Year 12
2 (11)
3 (23)
7 (18)
Technical school
7 (37)
1 (8)
8 (21)
0.53
Undergraduate degree
4 (21)
4 (31)
7 (18)
Postgraduate degree
2 (11)
4 (31)
7 (18)
Other
1 (5)
1 (8)
5 (13)
Not working
13 (72)
2 (17)
18 (47)
4 (22)
4 (33)
9 (24)
0.010
1 (6)
3 (25)
10 (26)
Working 40+ hours
0
3 (25)
1 (3)
Retired
9 (50)
1 (8)
13 (33)
0.047
Annual household income level
< $6,000
1 (6)
0
1 (3)
$6,000–35,000
3 (19)
1 (8)
9 (25)
0.32
$35,000–80,000
6 (38)
2 (15)
13 (36)
$80,000–180,000
4 (25)
8 (62)
12 (33)
> $180,000
2 (13)
2 (15)
1 (3)
Had private health insurance
15 (79)
11 (85)
34 (90)
0.56
Note: a Median months post-treatment compared by Independent Samples Kruskal-Wallis Test.
Significant (p < 0.05) group differences in bold.
137
Table 16
Baseline Physiological Measures for Cancer Type within Group
138
LIG
HIG
C
PCS
BCS
PCS
BCS
PCS
BCS
(n = 25)
(n = 19)
(n = 27)
(n = 13)
(n = 35)
(n = 40)
Outcome
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
[95% CI]
[95% CI]
[95% CI]
[95% CI]
[95% CI]
[95% CI]
176.0 (5.5)
162.2 (5.2)
174.4 (6.2)
164.0 (3.8)
173.5 (7.5)
164.1 (5.6)
Height (cm)
[173.7–178.3]
[159.7–164.7]
[171.9–177.0]
[161.7–166.3]
[170.8–176.1] [161.7–166.3]
81.8 (9.0)
70.1 (14.0)
83.8 (11.7)
74.9 (14.2)
83.3 (12.0)
70.7 (15.3)
Weight (kg)
[78.0–85.5]
[63.4–76.8]
[79.1–88.6]
[66.3–83.5]
[78.9–87.7]
[64.8–76.6]
26.4 (2.8)
26.6 (4.8)
27.6 (4.1)
27.9 (5.3)
28.0 (3.7)
26.3 (5.2)
BMI (kg/m2)
[25.3-27.6]
[24.3-28.9]
[26.0-29.3]
[24.7-31.1]
[26.7-29.3]
[24.4-28.3]
21.8 (4.8)
31.0 (8.5)
22.8 (5.1)
31.8 (5.5)
22.9 (4.9)
29.3 (7.1)
Body composition (BF%)
[19.8–23.8]
[26.9–35.1]
[20.7–24.8]
[28.5–35.1]
[21.1–24.6]
[26.5–32.0]
-8.7 (10.9)
1.8 (8.0)
-7.3 (7.0)
6.3 (9.1)
-10.9 (10.3)
0.5 (9.7)
Sit and reach (cm from toes)
[-13.2 to -4.2]
[-2.1 to 5.6]
[-10.1 to -4.5]
[0.8 to 11.7]
[-14.6–-7.1]
[-3.3–4.3]
720.9 (55.7)
705.1 (67.8)
730.9 (51.3)
760.8 (32.2)
728.2 (71.5)
738.0 (57.3)
Shoulder ROM (degrees)
[721.6–729.9]
[672.4–737.8]
[710.2–751.6]
[741.4–780.3]
[699.3–757.1] [715.8–760.3]
25.4 (5.4)
21.2 (5.0)
23.2 (4.5)
22.2 (5.9)
26.2 (6.5)
21.3 (6.7)
VO2peak (mL/kg/min)
[23.2–27.6]
[18.8–23.6]
[21.3–25.0]
[18.6–25.8]
[23.9–28.6]
[18.7–23.9]
6.9 (7.7)
7.8 (10.4)
6.2 (7.1)
8.6 (9.5)
8.0 (10.4)
8.0 (9.7)
Push-ups (repetitions)
[3.6–10.2]
[2.8–12.9]
[3.3–9.1]
[2.6–14.6]
[3.8–12.2]
[3.8–12.3]
99.2 (59.4)
50.4 (56.3)
66.4 (35.3)
55.6 (40.8)
75.1 (52.7)
62.4 (58.1)
Plank (seconds)
[73.5–124.9]
[22.3–77.6]
[52.1–80.6]
[29.7–81.6]
[53.8–96.4]
[37.3–87.5]
105.2 (35.5)
85.3 (28.0)
111.9 (32.6)
104.2 (43.4)
124.2 (35.5)
94.8 (24.8)
Leg Press 1RM (kg)
[89.9–120.6]
[71.8–98.7]
[98.8–125.1]
[76.6–131.7]
[109.9–138.6] [84.0–105.5]
Note: LIG = lower intensity group; HIG = higher intensity group; C = control group; PCS = prostate cancer survivors; BCS = breast cancer survivors.
Table 17
Baseline Quality of Life Outcome Measures for Cancer Type within Group
LIG
Outcome
139
PCS
(n = 25)
M (SD)
[95% CI]
81.7 (16.7)
[74.5–88.9]
22.4 (4.2)
[20.6–24.3]
21.1 (4.7)
[19.1–23.2]
19.1 (4.7)
[17.0–21.1]
19.0 (6.6)
[16.2–21.9]
HIG
BCS
(n = 19)
M (SD)
[95% CI]
81.8 (15.5)
[74.3–89.3]
21.1 (4.4)
[18.9–23.2]
20.7 (5.7)
[18.0–23.4]
19.2 (3.8)
[17.4–21.0]
20.8 (5.0)
[18.4–23.2]
PCS
(n = 27)
M (SD)
[95% CI]
84.2 (11.8)
[79.4–88.9]
22.9 (3.6)
[21.5–24.4]
20.2 (3.9)
[18.6–21.7]
19.8 (2.9)
[18.6–20.9]
21.3 (4.2)
[19.6–23.0]
C
BCS
(n = 13)
M (SD)
[95% CI]
83.7 (13.8)
[74.9–92.5]
21.7 (5.8)
[18.0–25.4]
23.2 (3.0)
[21.3–25.1]
18.3 (3.4)
[16.2–20.5]
20.5 (4.5)
[17.6–23.4]
PCS
(n = 35)
M (SD)
[95% CI]
86.2 (13.1)
[80.9–91.5]
23.5 (3.6)
[22.1–25.0]
20.3 (5.5)
[18.1–22.5]
19.7 (4.0)
[18.1–21.4]
22.6 (5.7)
[20.3–24.9]
BCS
(n = 40)
M (SD)
[95% CI]
87.6 (11.9)
[82.4–92.7]
23.3 (3.9)
[21.7–25.0]
22.6 (3.9)
[20.9–24.3]
20.0 (3.5)
[18.5–21.5]
21.6 (3.9)
[20.0–23.3]
FACT-G
(score out of 108)
Physical wellbeing
(score out of 28)
Social wellbeing
(score out of 28)
Emotional wellbeing
(score out of 24)
Functional wellbeing
(score out of 28)
Additional concerns
30.8 (8.1)
22.3 (6.1)
33.1 (5.3)
22.9 (6.2)
34.8 (5.9)
24.8 (6.4)
(score out of 40 for BCS, 48 for
[27.3–34.3]
[19.4–25.3]
[30.9–35.2]
[19.0–26.9]
[32.4–37.2]
[22.0–27.6]
PCS)
FACT-P or -B
112.5 (22.8)
104.1 (19.2)
117.2 (15.4)
106.6 (18.0)
121.0 (17.0)
112.3 (16.8)
(score out of 148 for BCS, 156 for
[102.7–122.4]
[94.9–113.3]
[111.0–123.4]
[95.2–118.1]
[114.1–127.8]
[105.1–119.6]
PCS)
Table 18
Baseline Physical Activity and Exercise Motivation Outcome Measures for Cancer Type within Group
140
LIG
HIG
C
PCS
BCS
PCS
BCS
PCS
(n = 25)
(n = 19)
(n = 27)
(n = 13)
(n = 35)
Outcome
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
[95% CI]
[95% CI]
[95% CI]
[95% CI]
[95% CI]
Physical activity level (MET hours
55.3 (119.2)
32.2 (36.5)
32.5 (36.8)
21.0 (23.2)
62.1 (65.0)
per week)
[3.7–106.9]
[14.6–49.8]
[17.7–47.4]
[6.3–35.8]
[35.9–88.4]
RAI
8.1 (7.1)
13.3 (5.3)
11.0 (6.1)
9.1 (6.4)
9.4 (7.3)
(score range -24 to 20)
[5.1–11.2]
[10.8–15.8]
[8.6–13.5]
[5.0–13.1]
[6.4–12.3]
Motivation
0.4 (0.7)
0.0 (0.1)
0.2 (0.6)
0.1 (0.4)
0.4 (0.7)
(score out of 4)
[0.1–0.7]
[0.0–0.1]
[0.0–0.5]
[-0.1–0.4]
[0.1–0.6]
External regulation
0.4 (0.7)
0.2 (0.3)
0.6 (0.9)
0.9 (1.1)
0.8 (0.9)
(score out of 4)
[0.1–0.7]
[0.1–0.3]
[0.2–0.9]
[0.2–1.6]
[0.5–1.2]
Introjected regulation
1.2 (0.9)
1.4 (0.8)
1.2 (1.1)
1.6 (1.1)
1.5 (1.2)
(score out of 4)
[0.8–1.6]
[1.0–1.8]
[0.8–1.7]
[0.9–2.3]
[1.0–2.0]
2.7 (0.9)
3.2 (0.8)
2.9 (0.8)
2.9 (0.7)
2.9 (0.9)
(score out of 4)
[2.3–3.1]
[2.8–3.6]
[2.6–3.2]
[2.4–3.3]
[2.6–3.2]
2.0 (1.2)
2.9 (1.1)
2.8 (0.8)
3.4 (1.2)
2.6 (1.1)
(score out of 4)
[1.5–2.6]
[2.4–3.5]
[2.4–3.1]
[1.6–3.1]
[2.2–3.0)
BCS
(n = 40)
M (SD)
[95% CI]
49.4 (63.7)
[21.8–76.9]
10.9 (7.1)
[7.9–14.0]
0.2 (0.6)
[0.0–0.5]
0.5 (0.6)
[0.2–0.7]
1.3 (0.8)
[1.0–1.7]
3.0 (0.8)
[2.6–3.3]
2.6 (1.3)
[2.1–3.2]
Table 19
Baseline Fatigue Outcome Measures for Cancer Type within Group
141
LIG
HIG
C
PCS
BCS
PCS
BCS
PCS
BCS
(n = 25)
(n = 19)
(n = 27)
(n = 13)
(n = 35)
(n = 40)
Outcome
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
[95% CI]
[95% CI]
[95% CI]
[95% CI]
[95% CI]
[95% CI]
PFS
4.0 (2.3)
4.7 (2.1)
3.5 (2.2)
4.1 (2.1)
2.9 (1.9)
3.2 (2.0)
(score out of 10)
[3.1–5.0]
[3.6–5.7]
[2.6–4.4]
[2.8–5.5]
[2.6–4.4]
[2.3–4.0]
Behavioural fatigue
2.9 (2.8)
4.0 (2.8)
2.2 (2.2)
3.0 (2.7)
2.0 (2.2)
1.8 (2.2)
(score out of 10)
[1.7–4.1]
[2.6–5.3]
[1.3–3.1]
[1.3–4.7]
[1.0–2.9]
[0.9–2.8]
Affective fatigue
3.7 (3.1)
5.0 (2.8)
3.5 (3.2)
4.1 (3.2)
2.8 (2.8)
2.9 (3.0)
(score out of 10)
[2.4–5.0]
[3.6–6.3]
[2.2–4.8]
[2.1–6.1]
[1.7–4.0]
[1.6–4.2]
Sensory fatigue
5.0 (2.4)
5.1 (2.2)
4.4 (2.2)
4.6 (2.0)
3.5 (1.8)
4.1 (2.1)
(score out of 10)
[3.9–6.0]
[4.0–6.1]
[3.5–5.3]
[3.3–5.8]
[2.7–4.2]
[3.2–5.0]
Cognitive fatigue
4.6 (2.0)
4.7 (1.8)
4.0 (1.8)
4.7 (1.3)
3.4 (1.6)
3.8 (1.7)
(score out of 10)
[3.7–5.4]
[3.8–5.5]
[3.2–4.7]
[3.9–5.6]
[2.7–4.1]
[3.1–4.5]
5.3 Attendance, Compliance, and Safety
5.3.1 Program attendance.
As illustrated in Table 20, there were no significant differences between groups
for exercise (p = 0.20) or SGP attendance (p = 0.24). The most common reasons for
missing a session were work (19.2%), holiday (17.5%) and sickness (15%).
Table 20
Participant Attendance at Exercise and SGP Sessions for Each Group
Exercise attendance
SGP attendance
(% of sessions attended) (% of sessions attended)
M (SD)
M (SD)
LIG
44
87.1 (12.7)
86.7 (15.5)
HIG 40
90.2 (11.2)
89.8 (12.6)
Note: LIG = lower intensity group; HIG = higher intensity group
Group
n
5.3.2 Aerobic compliance.
Both groups complied well with the aerobic exercise prescription, staying within
10% of their target HR. However, there was a significant difference between the LIG
and HIG for aerobic compliance (p = 0.001), with the LIG exercising at their assigned
intensity of 60 to 65% VO2peak more often than the HIG complied to their assignment
of 75 to 80% VO2peak (Table 21 and Figure 3). This indicated that the lower intensity
aerobic exercise targets were more achievable for the breast and prostate cancer
survivors to comply with compared to the higher intensity aerobic exercise targets. The
data for three men were excluded from the aerobic compliance analysis because the
Team2 Polar system was unable to provide reliable HR data, as these men had
arrhythmias. All three men were in the HIG.
142
Table 21
Achieved Aerobic Workloads and Compliance during Intervention
VO2peak during aerobic
HR during aerobic exercise Aerobic compliance (% of
exercise
(BPM)
target HR)
M (SD)
M (SD)
M (SD)
LIG
44
60.7% (5.3)
109.8 (14.9)
97.1 (8.5)
HIG 37
112.3 (11.5)
70.1% (6.7)
90.4 (8.6)
Note: LIG = lower intensity group; HIG = higher intensity group. Significant (p < 0.05) group differences
are in bold.
Group
n
Although the relative workload (VO2peak during aerobic exercise) indicated that
the groups exercised at significantly different aerobic intensities (p < 0.001), the
absolute workload (HR during aerobic exercise) showed that the groups were almost
identical (p = 0.56) (Table 21). The range of aerobic compliance and workloads for
participants in each group are graphically presented in Figures 3 and 4.
143
Line set at
100% aerobic
compliance, i.e.
target intensity
Figure 3. Scatter plot of breast and prostate cancer survivors’ aerobic compliance,
divided by assigned exercise intensity.
As seen in Figure 3, the LIG had twice as many participants exercise above their
target intensity than the HIG. Members of the LIG exercised up to 21% higher than their
prescribed intensity, while members of the HIG only exceeded their prescription by 7%
at most. There were no significant differences between cancer types for compliance (p =
0.66).
144
Note: the boxes represent the range of prescribed intensity for each group.
Figure 4. Scatter plot of achieved relative aerobic intensity according to assigned
exercise intensity.
It can be seen in Figure 4 that the participants exercised between 50 and 84%
VO2peak. Although the groups did not maintain the prescribed 15% difference in
aerobic workload, and the HIG fell below their target range, it can be seen that the HIG
members exercised on average at a 9% higher VO2peak than the LIG.
5.3.3 Resistance workload.
Both groups complied with their target resistance exercise prescriptions. The
average initial and progressed intensities indicated that the LIG performed resistance
exercises at 50 to 65% 1RM, and the HIG performed resistance exercise at 65 to 80%
145
1RM, maintaining the prescribed 15% difference between the groups. The HIG (M [SD]
= 1,345.9 [340.9] kg-repetitions) performed a significantly greater resistance training
workload (p < 0.001) than the LIG (M [SD] = 971.7 [189.6] kg-repetitions), which
confirmed that the groups performed different relative and absolute intensities of
resistance training.
5.3.4 Rating of perceived exertion.
There was no difference between the LIG and HIG in the rating of the perceived
exertion for each session (p = 0.14). The mean RPE for the LIG was 3.7 (SD 0.6) and
for the HIG was 3.9 (SD 1.0). Overall, the participants consistently rated their exercise
sessions as ‘moderate’ to ‘somewhat hard’.
5.3.5 Safety.
No adverse events were reported during the group exercise program.
5.4 Outcome Differences between Groups
The change scores from baseline to post-intervention for all physiological and
psychological assessments were compared between the LIG, HIG and C groups, while
adjusting for cancer type, age of participants and months post-treatment. The adjusted
change scores from post-intervention to follow up were compared for the LIG and HIG.
Not all participants returned for the follow-up assessment. The participants’
characteristics are presented by group and cancer type in Table 22. Sample sizes for
each time point are indicated in the relevant tables and figures. The figures in this
section show the raw group means and standard deviations at all assessments, while the
adjusted change scores are presented in the tables. In the tables, the group of cancer type
differences indicate the omnibus F test, while the text presents the post-hoc comparisons
between specific groups. The raw means and standard deviations of the outcome
146
measures for the groups at all assessments, separated into the two cancer types, are
reported in Appendix E.
Table 22
Characteristics of Participants (n = 72) Who Completed the Follow-up Assessment
Measure
Age (years)
Months posttreatment
LIG
PCS
(n = 21)
M (SD)
64.8 (6.8)
9.7 (11.3)
BCS
(n = 15)
M (SD)
59.5 (7.3)
13.9 (10.8)
HIG
PCS
(n = 24)
M (SD)
66.1 (6.8)
11.2 (16.1)
BCS
(n = 12)
M (SD)
54.0 (9.1)
12.3 (17.4)
n (%)
n (%)
n (%)
n (%)
Stage
I
5 (24)
7 (47)
3 (13)
5 (42)
II
13 (62)
5 (33)
15 (65)
7 (58)
III
3 (14)
3 (20)
5 (22)
0
Note: LIG = lower intensity group; HIG = higher intensity group; PCS = prostate cancer survivors; BCS
= breast cancer survivors.
Table 23
Comparison between Participants who Dropped and Completed Follow Up Assessment
Measure
Age (years)
Months posttreatment
Drop outs
PCS
BCS
(n = 6)
(n = 5)
M (SD)
M (SD)
62.7 (6.2)
51.8 (14.1)
6.7 (5.4)
12.8 (15.7)
Follow Ups
PCS
BCS
(n = 45)
(n = 27)
M (SD)
M (SD)
65.58 (6.7)
57.07 (8.5)
10.8 (13.8)
n (%)
n (%)
n (%)
Stage
I
1 (16.7)
2 (40.0)
7 (15.2)
II
5 (83.3)
2 (40.0)
29 (63.0)
III
0
1 (20.0)
10 (21.7)
Note: PCS = prostate cancer survivors; BCS = breast cancer survivors.
15.1 (13.9)
n (%)
15 (48.4)
12 (38.7)
4 (12.9)
There were no differences between those who had to drop out and those who
completed the follow up on age (p = 0.057) and months post treatment (p = 0.30) (Table
23). There were no significant interactions between drop outs and cancer type or groups
on age or group. There was no difference between drop outs and those who followed up
on cancer stage within the men (p = 0.44) or women (p = 0.85).
147
5.4.1 Physiological outcomes.
5.4.1.1 Anthropometrics.
From baseline to post-intervention, the decrease in BF% in the HIG was
significantly greater than in the C (p = 0.002), but not the LIG (p = 0.14) (Figure 5).
There was no significant difference for change between the LIG and C (p = 0.37). There
was no difference between the HIG and LIG for change in BF% from post-intervention
to follow up. Weight (kg) did not differ between the groups nor change between any
assessments (Table 24).
Note: error bars indicate + 1 SD. Sample sizes for groups at post-intervention: LIG = 44, HIG = 40, C =
75. Sample sizes for groups at follow up: LIG = 32, HIG = 32.
Figure 5. Raw group means for BF% at baseline, post-intervention and follow up.
148
Table 24
Adjusted Mean Changes between Assessment Periods for Weight (kg) and Body Fat (%)
Assessment period
Outcomes
LIG
HIG
C
Group differences
(n = 44)
(n = 40)
(n = 75)
F
p
Changes from baseline
Weight (kg)
0.3
-0.2
-0.1
0.8
0.42
to post-intervention
Body fat (%)
-1.1
-2.3a
-0.3a
6.2
0.003
Changes from post(n = 32)
(n = 32)
intervention to follow
Weight (kg)
-0.2
-0.5
0.3
0.56
up
Body fat (%)
-0.9
-1.1
0.1
0.82
Note: LIG = lower intensity group; HIG = higher intensity group; C = control group. Significant (p <
0.05) group differences in bold. a post hoc difference between HIG and C.
149
5.4.1.2 Flexibility.
There were no significant differences between the groups on change in sit and
reach scores from baseline to post-intervention. From post-intervention to follow up, the
LIG became less flexible while the HIG maintained their improvement (Figure 6 and
Table 25).
Figure 6. Raw group means for sit and reach at baseline, post-intervention and follow
up.
Table 25
Adjusted Mean Changes between Assessment Periods for Sit and Reach (cm from Toes)
Assessment period
LIG
HIG
C
Group differences
Changes from baseline to post(n = 44)
(n = 40)
(n = 75)
F
p
intervention
3.6
1.7
1.5
3.0
0.055
Changes from post-intervention to follow
(n = 32)
(n = 32)
up
-1.0
0.6
4.3
0.043
Note: LIG = lower intensity group; HIG = higher intensity group; C = control group. Significant
(p < 0.05) group differences in bold.
150
The LIG improved shoulder ROM from baseline to post-intervention more than
the C (p = 0.016), but not the HIG (p = 0.11) (Figure 7). There was no difference
between the HIG and C (p = 0.99) for change in shoulder ROM from baseline to postintervention. There was some loss of upper body flexibility from post-intervention to
follow up; however, there was no difference between the LIG and HIG on change in
shoulder ROM (Table 26).
Figure 7. Raw group means for shoulder ROM at baseline, post-intervention and follow
up.
Table 26
Adjusted Mean Changes at both Assessment Periods on Shoulder ROM (Degrees)
Assessment period
LIG
HIG
C
Group differences
(n = 40)
(n = 75)
F
p
intervention
35.9b
12.6
6.5b
4.4
0.015
Changes from post-intervention to
(n = 32)
(n = 32)
follow up
-12.0
-2.5
1.3
0.26
0.05) group differences in bold.. b post hoc difference between LIG and C
151
5.4.1.3 VO2peak.
In response to the exercise intervention, both the LIG and HIG improved their
VO2peak at a similar rate (p = 0.83) and each were significantly more than the C (p <
0.001 for both). From post-intervention to follow up, the HIG maintained their
VO2peak, while the LIG lost most of the intervention gains (Figure 8 and Table 27).
Error bars indicate + 1 SD. Minimum targets to reduce CVD risk derived from Kodama et al. (2009).
Sample sizes for groups at post-intervention: LIG = 44, HIG = 40, C = 75. Sample sizes for groups at
follow up: LIG = 32, HIG = 32.
Figure 8. Raw group means for VO2peak at baseline, post-intervention and follow up.
152
Table 27
Adjusted Mean Changes in VO2peak (mL/kg/mind) between Assessment Periods
Assessment period
LIG
HIG
C
Group differences
(n = 40)
(n = 75)
F
p
intervention
1.7b
2.2a
-0.4a,b
16.7
< 0.001
(n = 32)
(n = 32)
follow up
-1.3
0.2
5.6
0.021
0.05) group differences in bold.. a post hoc difference between HIG and C. b post hoc difference between
LIG and C.
Change in VO2peak was modelled against the relative aerobic exercise intensity
achieved in order to further explore this relationship, regardless of the prescribed
aerobic intensity. This was done because of the poor compliance of participants to their
prescribed aerobic exercise intensity. A regression analysis, adjusting for age and
months post-treatment, indicated no significant relationship between the two variables
(β = 0.11, F = 0.88, p = 0.35) (Figure 9). Together, the analyses of group differences
and relationship of individual aerobic exercise intensity to change in VO2peak indicated
that there were no differences in cardiorespiratory fitness improvements between the
breast and prostate cancer survivors who, on average, exercised between 61 to 70%
VO2peak.
153
Lines indicate line of best fit with 95% confidence interval for mean relative aerobic exercise intensity
achieved.
Figure 9. Scatter plot of relationship between relative aerobic exercise intensity
achieved and change in VO2peak.
154
5.4.1.4 Muscular strength and endurance.
From baseline to post-intervention, the HIG increased the number of completed
push-ups significantly more than both the LIG (p = 0.007) and the C (p < 0.001). The
improvements for the LIG and C were not significantly different (p = 0.79). Changes
from post-intervention to follow up were similar between the LIG and HIG (Figure 10
and Table 28).
Error bars indicate + 1 SD. Sample sizes for groups at post-intervention: LIG = 44, HIG = 40, C = 75.
Sample sizes for groups at follow up: LIG = 32, HIG = 32.
Figure 10. Raw group means for push-ups at baseline, post-intervention and follow up.
Table 28
Adjusted Mean Changes in Push-ups (Repetitions) between Assessment Periods
Assessment period
LIG
HIG
C
Group differences
(n = 40)
(n = 75)
F
p
intervention
3.0c
6.6a,c
1.8a
9.4
< 0.001
(n = 32)
(n = 32)
follow up
0.1
0.2
0.0
0.96
0.05) group differences in bold.. a post hoc difference between HIG and C. c post hoc difference between
HIG and LIG.
155
As seen in Figure 11, both the LIG and HIG improved their times on the plank
test to a similar extent (p = 0.99) and did so significantly more than the C (p = 0.024 and
0.011, respectively). Both groups decreased their times at follow up (Table 29).
Figure 11. Raw group means for plank time at baseline, post-intervention and follow
up.
Table 29
Adjusted Mean Changes in Plank Time (Seconds) between Assessment Periods
Assessment period
LIG
HIG
C
Group differences
(n = 40)
(n = 75)
F
p
intervention
21.2b
23.5a
5.5a,b
4.8
0.005
(n = 32)
(n = 32)
follow up
-18.4
-6.8
2.2
0.14
0.05) group differences in bold.. a post hoc difference between HIG and C. b post hoc difference between
LIG and C.
156
The HIG improved lower body strength significantly more than the C (p =
0.007), but not the LIG (p = 0.16), from baseline to post-intervention (Figure 12). The
improvement of the LIG was not significantly different from the C (p = 0.78). Both
intervention arms maintained their lower body strength to follow up (Table 30).
Figure 12. Raw group means for leg press 1RM at baseline, post-intervention and
follow up.
Table 30
Adjusted Mean Changes in Leg Press 1RM (kg) between Assessment Periods
Assessment period
LIG
HIG
C
Group differences
(n = 40)
(n = 75)
F
p
intervention
14.4
24.6a
8.9a
5.5
0.010
(n = 32)
(n = 32)
follow up
-8.6
3.8
3.2
0.08
0.05) group differences in bold.. a post hoc difference between HIG and C.
157
5.4.2 Psychological outcomes.
All three groups similarly increased their mean FACT-G scores between
baseline and post-intervention (Figure 13). Although the omnibus F test indicated that
there were significant differences between the groups on change of emotional wellbeing
subscale scores from baseline to post-intervention, the Bonferroni post-hoc tests showed
that the differences between each group did not reach significance (LIG v. HIG: p =
0.99; LIG v. C: p = 0.18; HIG v. C: p = 0.07).
Figure 13. Raw group means for general QOL at baseline, post-intervention and follow
up.
158
There were no significant differences between groups on changes for any other
subscale of the FACT-G from baseline to post-intervention. The intensity arms similarly
maintained all measures of general QOL from post-intervention to follow up (Table 31).
Table 31
Adjusted Mean Change on Quality of Life Outcomes between Assessment Periods
Assessment
period
Outcome
Score
range
LIG
HIG
C
Group
differences
F
p
0.5
0.60
1.1
0.32
1.9
0.15
3.1
0.048d
0.2
0.83
(n = 44)
(n = 40)
(n = 75)
3.0
4.8
3.1
1.4
1.7
0.7
-0.4
0.3
1.0
0.8
1.1
-0.1
1.2
1.6
1.6
(n = 36)
(n = 36)
Changes
FACT-G
0–108
-1.4
-2.0
0.1
0.77
from postPhysical wellbeing
0–28
-1.1
-1.0
0.0
0.85
intervention Social wellbeing
0–28
0.5
-0.5
1.5
0.23
to follow up Emotional wellbeing
0–24
-0.6
0.6
3.5
0.065
0–28
-0.2
-1.2
1.8
0.18
0.05) omnibus group differences in bold.. d No significant post-hoc differences between groups.
Changes
from baseline
to postintervention
FACT-G
Physical wellbeing
Social wellbeing
Emotional wellbeing
0–108
0–28
0–28
0–24
0–28
Among the prostate cancer survivors, despite the omnibus F statistic indicating
possible group differences on change in additional concerns from baseline to postintervention, the Bonferroni post-hoc tests showed that the groups were similar in their
response (LIG v. HIG: p = 0.053; LIG v. C: p = 0.063; HIG v. C: p = 0.99). At baseline
and post-intervention, respectively, 72% and 69% of men reported that they could not
have and maintain an erection, with 79% of all men seeing no improvement or a
worsening in sexual function over the course of the intervention. Additionally, 57% at
baseline and 60% at post-intervention reported being completely dissatisfied with their
sex lives, with 80% of men reporting no improvement or a worsening of their sex lives.
The lack of differences in additional concern changes led to similar changes in the
FACT-P scores between the groups from baseline to post-intervention. There were no
159
differences between intervention groups from post-intervention to follow up on change
in prostate cancer–specific QOL (Table 32).
Sample sizes for groups: LIG = 21; HIG = 24.
Figure 14. Raw group means for prostate cancer–specific additional concerns and
FACT-P scores at baseline, post-intervention and follow up.
Table 32
Adjusted Mean Change on Prostate Cancer–specific Quality of Life Outcomes between
Assessment Periods
Assessment
period
Changes from
baseline to
postintervention
Changes from
postintervention to
follow up
Outcome
Additional
concerns for
PCS
FACT-P
Score
range
Group
differences
F
p
LIG
HIG
C
(n = 25)
(n = 27)
(n = 35)
0–48
4.3
1.4
1.4
3.8
0.028 d
0–156
7.7
(n = 21)
3.2
(n = 24)
4.2
1.1
0.34
Additional
concerns for
0–48
-1.5
-1.3
0.0
0.94
PCS
FACT-P
0–156
-2.6
-1.1
0.2
0.66
0.05) omnibus group differences in bold. d No significant post-hoc differences between groups.
160
Among the breast cancer survivors, the HIG improved their additional concerns
more than the C (p = 0.014) and similarly to the LIG (p = 0.09) from baseline to postintervention (Figure 15). The Bonferroni post-hoc tests indicated that this did not
translate to significant differences between the groups on total FACT-B scores (LIG v.
HIG: p = 0.08; LIG v. C: p = 0.99; HIG v. C: p = 0.07), despite the omnibus F statistic
reaching significance (Table 33). The changes were similar for the groups between postintervention and follow up on breast cancer–specific QOL.
Error bars indicate + 1 SD. Sample sizes for groups at post-intervention: LIG = 19, HIG =13, C =40.
Sample sizes for groups at follow up: LIG = 15; HIG = 12.
Figure 15. Raw group means for breast cancer–specific additional concerns and FACTB scores at baseline, post-intervention and follow up.
161
Table 33
Adjusted Mean Change on Breast Cancer–specific Quality of Life Outcomes between
Assessment Periods
Assessment
period
Changes from
baseline to
postintervention
Changes from
postintervention to
follow up
Outcome
Additional
concerns for
BCS
FACT-B
Score
range
Group
differences
F
p
LIG
HIG
C
(n = 19)
(n = 13)
(n = 40)
0–40
0.7
3.6a
-0.1a
4.5
0.016
0–148
3.1
(n = 15)
11.6
(n = 12)
3.2
3.3
0.045 d
Additional
concerns for
0–40
1.0
0.7
0.1
0.80
BCS
FACT-B
0–148
-1.0
-4.3
0.7
0.41
0.05) group differences in bold. a post hoc difference between HIG and C. d No significant post-hoc
differences between groups.
162
5.4.2.2 Exercise motivation.
The participants from all groups increased their overall exercise motivation from
baseline to post-intervention, with no observed differences between the groups on the
RAI. The HIG continued to increase their overall exercise motivation to follow up,
while the LIG returned towards baseline scores (Figure 16).
Figure 16. Raw group means for RAI scores at baseline, post-intervention and follow
up.
The changes on all exercise motivation results can be seen in Table 34. While
the intensity arms improved similarly during the intervention on most measures, the
HIG maintained more aspects of exercise motivation than the LIG at the follow up.
163
Table 34
Adjusted Mean Change in Exercise Motivation Outcomes between Assessment Periods
Assessment
period
Changes
from
baseline to
postintervention
Outcome
RAI
Amotivation
External
regulation
Introjected
regulation
Identified
regulation
Intrinsic
regulation
Score
range
LIG
HIG
C
Group
differences
F
p
0.8
0.45
1.9
0.15
0.8
0.44
-24–20
0–4
0–4
(n = 44)
2.1
-0.1
0.1
(n = 40)
1.3
0.0
0.0
(n = 75)
1.1
-0.2
-0.1
0–4
0.4
0.4
0.0
2.8
0.07
0–4
0.4b
0.3a
0.0a,b
5.8
0.004
0–4
0.5
0.4
0.1
2.9
0.06
(n = 36)
(n = 36)
RAI
-24–20
-2.5
0.6
15.5 < 0.001
Amotivation
0–4
0.2
-0.1
6.0
0.017
External
0–4
0.1
-0.1
4.8
0.033
Changes
regulation
from postIntrojected
0–4
-0.1
-0.1
0.0
0.95
intervention
regulation
to follow up
Identified
0–4
-0.3
0.0
4.1
0.047
regulation
Intrinsic
0–4
-0.4
0.0
7.8
0.007
regulation
0.05) group differences in bold. a post hoc difference between HIG and C. b post hoc difference between
LIG and C.
As seen in Figure 17, both the LIG and HIG increased their motivation to
exercise to meet personal goals more than the C (p = 0.005 and 0.048, respectively)
from baseline to post-intervention; however, the two intervention arms were not
significantly different from each other (p = 0.99). From post-intervention to follow up,
the HIG maintained this area of motivation, while the LIG returned towards their
baseline scores.
164
Figure 17. Raw group means for identified regulation scores at baseline, postintervention and follow up.
There were no significant differences between the three groups on change in the
enjoyment of exercise from baseline to post-intervention (see Figure 18). Though both
the LIG and HIG groups increased their enjoyment of exercise during the intervention,
the HIG continued to enjoy exercise at the same level at follow up as they did postintervention, while the LIG returned towards their baseline scores (Table 34).
165
Figure 18. Raw group means for intrinsic regulation scores at baseline, postintervention and follow up.
There were no differences between any group on changes in amotivation or the
extrinsic motivation subscales from baseline to post-intervention. From postintervention to follow up, there were significant differences between the LIG and HIG
on changes in amotivation and external regulation. The HIG slightly decreased their
aversion to exercise and their need for external control, while the LIG had small
increases in these two areas (Table 34).
166
5.4.2.3 Fatigue.
Most participants in this study reported feeling mild or no fatigue. As seen in
Figure 19, the LIG showed the greatest reduction in their overall fatigue levels, from
being moderate to mild, while the other groups started out feeling mildly fatigued on
average. The LIG decreased their overall fatigue score significantly more than the C (p
= 0.038). There was no difference between the LIG and the HIG (p = 0.11). Similarly,
the LIG had a greater reduction in cognitive fatigue than the C (p = 0.022). Again, there
was no difference between the LIG and HIG (p = 0.99). From post-intervention to
follow up, the LIG returned towards baseline levels of cognitive fatigue compared to the
HIG. There were no other differences between the groups on changes in fatigue from
post-intervention to follow up (Table 35).
Error bars indicate + 1 SD. Categories for fatigue given in PFS scoring directions (Piper et al., 1998).
Sample sizes for groups at post-intervention: LIG = 44, HIG = 40, C = 75. Sample sizes for groups at
follow up: LIG = 36, HIG = 36.
Figure 19. Raw group means for PFS scores at baseline, post-intervention and follow
up.
167
Table 35
Adjusted Mean Change in Fatigue Outcomes between Assessment Periods
Assessment
period
Baseline to
postintervention
Outcome
Score
range
LIG
HIG
C
PFS
Behavioural
fatigue
Affective
fatigue
Sensory fatigue
Cognitive
fatigue
0–10
0–10
(n = 44)
-1.2b
-1.3
(n = 40)
-0.4
-0.8
(n = 75)
-0.4b
-0.4
0–10
-1.6
-0.6
-0.6
2.0
0.15
0–10
0–10
-1.0
-0.8b
-0.2
-0.2
-0.4
0.0b
2.8
3.9
0.06
0.022
Postintervention
to follow up
Group
differences
F
p
3.7
0.027
2.1
0.13
(n = 36)
(n = 36)
PFS
0–10
0.3
0.2
0.1
0.72
Behavioural
0–10
0.3
0.4
0.0
0.87
fatigue
Affective
0–10
0.1
0.5
0.3
0.56
fatigue
Sensory fatigue
0–10
0.5
0.0
1.4
0.25
Cognitive
0–10
0.6
0.0
4.3
0.042
fatigue
0.05) group differences in bold. a post hoc difference between HIG and C. b post hoc difference between
LIG and C.
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5.5 Outcome Differences between Cancer Types
The outcome scores between the cancer types were compared simultaneously
during the ANCOVAs used to compare groups, so that the comparisons of each main
effect accounted for the other independent variable. Attendance and compliance to the
intervention were similar between the breast and prostate cancer survivors (Table 36).
The only variable that significantly differed between the cancer types was average
resistance workload. As the leg press 1RMs for the prostate cancer survivors were
significantly higher than the breast cancer survivors (p < 0.001), throughout the
intervention, the men were required to lift heavier weights.
Table 36
Attendance and Performance for Prostate and Breast Cancer Intervention Participants
Measure
PCS
(n = 52)
M (SD)
BCS
(n = 32)
M (SD)
Cancer type differences
p
Exercise attendance
89.1 (12.0)
87.8 (12.3)
0.83
(% of sessions attended)
SGP attendance
86.0 (15.1)
91.5 (12.2)
0.07
(% of sessions attended)
Aerobic compliance
94.0 (9.3)
94.3 (9.0)
0.66
(% of target HR)
Resistance workload
1232.1 (344.2) 1002.0 (241.8)
< 0.001
(kg-repetitions)
RPE
3.7 (0.7)
3.9 (0.9)
0.17
Note: PCS = prostate cancer survivors; BCS = breast cancer survivors. Significant (p < 0.05) group
differences in bold.
169
There were no differences between cancer types on changes for any variable at
either assessment point, except for the change in leg press 1RM from baseline to postintervention (Tables 37 to 40). As seen in Figure 20, although the breast and prostate
cancer survivors responded similarly to their group assignments (group * cancer type: F
= 0.4, p = 0.68), the breast cancer survivors showed greater magnitudes of improvement
on the leg press 1RM than did the prostate cancer survivors for their intensity groups
from baseline to post-intervention.
a) Prostate cancer survivors
b) Breast cancer survivors
Sample sizes for groups within cancer types: PCS-LIG = 25, PCS-HIG = 27, PCS-C = 35, BCS-LIG = 19,
BCS-HIG = 13, BCS-C = 40 (Note: PCS = prostate cancer survivors; BCS = breast cancer survivors).
Figure 20. Raw group means for leg press 1RM (kg) for (a) prostate and (b) breast
cancer survivors at baseline, post-intervention and follow up.
170
While there were no other significant main effects for cancer type, there were
three significant interactions between cancer type and group assignment for changes in
outcomes from baseline to post-intervention. As seen in Figure 21, among the breast
cancer survivors, the HIG achieved over four times the improvement in push-ups
compared to the LIG. Among the prostate cancer survivors, the HIG and LIG had
similar improvements (F = 4.8, p = 0.010).
Sample sizes for groups within cancer types: PCS-LIG = 25, PCS-HIG = 27, PCS-C = 35, BCS-LIG = 19,
BCS-HIG = 13, BCS-C = 40 (Note: PCS = prostate cancer survivors; BCS = breast cancer survivors).
Figure 21. Raw group means for push-ups (repetitions) for (a) prostate and (b) breast
171
Within the prostate cancer survivors, the LIG showed the largest increase in the
introjected regulation subscale of the BREQ-2, while the HIG increased less (F = 3.3, p
= 0.041). In contrast, within the breast cancer survivors, the HIG improved, while the
LIG did not change (Figure 22). Similar patterns were seen on the emotional wellbeing
subscale of the FACT-G (F = 3.1, p = 0.047) (Figure 23).
Sample sizes for groups: PCS-LIG = 25, PCS-HIG = 27, PCS-C = 35, BCS-LIG = 19, BCS-HIG = 13,
BCS-C = 40 (Note: PCS = prostate cancer survivors; BCS = breast cancer survivors).
Figure 22. Raw group means for introjected regulation for (a) prostate and (b) breast
172
Sample sizes for groups: PCS-LIG = 25, PCS-HIG = 27, PCS-C = 35, BCS-LIG = 19, BCS-HIG = 13,
BCS-C = 40 (Note: PCS = prostate cancer survivors; BCS = breast cancer survivors).
Figure 23. Raw group means for emotional wellbeing for (a) prostate and (b) breast
173
There were no significant differences between cancer types, or interactions
between group and cancer type, for change in any outcome from post-intervention to
follow up.
Table 37
Adjusted Changes for Cancer Types on Physiological Outcomes between Assessment
Periods
Assessment
period
Baseline to postintervention
Outcome
Weight (kg)
Body fat (%)
Sit and reach (cm from
toes)
VO2peak (mL/kg/min)
Plank time (seconds)
Leg press 1RM (kg)
Prostate cancer
survivors
(n = 87)
0.1
-1.0
2.5
Breast cancer
survivors
(n = 72)
-0.2
-1.5
2.0
Cancer type
differences
p
0.37
0.38
0.60
15.0
1.4
3.6
21.8
8.8
(n = 39)
0.1
-0.3
-0.6
21.7
1.0
4.1
11.7
23.2
(n = 25)
-0.8
-1.8
0.2
0.50
0.39
0.64
0.07
0.003
-8.1
-0.4
0.0
-11.9
-0.2
0.85
0.55
0.84
0.86
0.56
Postintervention to
follow up
Weight (kg)
Body fat (%)
Sit and reach (cm from
toes)
-6.3
VO2peak (mL/kg/min)
-0.8
0.4
Plank time (seconds)
-13.4
Leg press 1RM (kg)
-4.7
Note: Significant (p < 0.05) cancer type differences in bold.
174
0.19
0.07
0.36
Table 38
Adjusted Changes for Cancer Types on Quality of Life Outcomes between Assessment
Periods
Assessment
period
Baseline to
postintervention
Postintervention to
follow up
Outcome
FACT-G
Physical wellbeing
Social wellbeing
Emotional wellbeing
FACT-G
Physical wellbeing
Social wellbeing
Emotional wellbeing
Prostate cancer
survivors
(n = 87)
3.1
1.3
0.0
0.5
1.4
(n = 45)
-1.2
-0.9
0.5
-0.5
-0.3
Breast cancer
survivors
(n = 72)
4.2
1.2
0.7
0.7
1.5
(n = 27)
-2.3
-1.2
-0.6
0.5
-1.1
Cancer type
differences
p
0.54
0.94
0.33
0.58
0.86
0.65
0.75
0.25
0.16
0.36
Table 39
Adjusted Changes for Cancer Types on Exercise Motivation Outcomes between
Assessment Periods
Assessment
period
Baseline to
postintervention
Postintervention to
follow up
Outcome
RAI
Amotivation
External regulation
Introjected
regulation
RAI
Amotivation
External regulation
Introjected
regulation
Prostate cancer
survivors
(n = 87)
1.9
-0.1
0.0
Breast cancer
survivors
(n = 72)
1.1
-0.1
0.0
Cancer type
differences
p
0.30
0.82
0.82
0.3
0.2
0.95
0.3
0.5
(n = 45)
-1.2
0.0
0.0
0.2
0.2
(n = 27)
-0.6
0.0
0.0
0.88
0.12
0.0
-0.2
0.49
-0.2
-0.2
0.0
-0.2
0.23
0.72
175
0.49
0.95
0.76
Table 40
Adjusted Changes for Cancer Types on Fatigue Outcomes between Assessment Periods
Assessment
period
Baseline to postintervention
Post-intervention
to follow up
Outcome
PFS
Behavioural fatigue
Affective fatigue
Sensory fatigue
Cognitive fatigue
PFS
Behavioural fatigue
Affective fatigue
Sensory fatigue
Cognitive fatigue
Prostate cancer
survivors
(n = 87)
-0.6
-0.8
-0.7
-0.6
-0.4
(n = 45)
0.4
0.5
0.0
0.6
0.4
Breast cancer
survivors
(n = 72)
-0.7
-0.9
-1.2
-0.5
-0.3
(n = 27)
0.1
0.1
0.5
-0.2
0.1
Cancer type
differences
p
0.84
0.85
0.35
0.69
0.58
0.61
0.53
0.49
0.10
0.31
5.6 Physical Activity Levels
Due to the potential to over-report physical activity when completing the IPAQ
(Lee et al., 2011b), the scores were compared to include and exclude outliers (these
were participants who reported a total MET hours per week greater than three standard
deviations from the mean—at baseline, this was 183.9 and at follow up, it was 250.2
MET hours per week). As the focus of the research was to determine the long-term
change in physical activity levels among the intervention participants, relative to what
they were completing prior to the program, the physical activity levels were not
assessed at post-intervention.
At baseline, the mean physical activity levels for all three groups were more than
three times the recommended PAG of nine MET hours per week (Table 41), with 76%
of all participants meeting or exceeding this threshold (Physical Activity Guidelines
Advisory Committee, 2008). The omnibus F statistic indicated significant group
differences for total MET hours per week; however, the Tukey’s post-hoc tests did not
identify any between-group differences (HIG v. LIG: p = 0.91; HIG v. C: p = 0.06; LIG
v. C: p = 0.15). As the reported physical activity levels results were improbably high for
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this group, four outliers were removed from the total MET hours per week (three from
PCS-C and one from BCS-C). Removing the outliers eliminated the group differences
on physical activity levels.
At the follow-up assessment, 86% of all intervention participants were meeting
the PAG—an increase of 10%. Among those intervention participants not meeting the
PAG at baseline, 79% reported more than nine MET hours per week at follow up. The
two intervention groups engaged in similar levels of physical activity, even when
outliers were removed. Although initially it appeared that there was no difference
between the cancer types for levels of physical activity, after removing the single outlier
(BCS-LIG), the analysis showed that the women were performing significantly less total
physical activity, deriving from significantly less moderate physical activity (Table 42).
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Table 41
Physical Activity Levels at Baseline and Follow Up as Measured by IPAQ
PCS
Follow up
45
Outcome
Statistic
n
Baseline
87
MET hours per week
M (SD)
42.6 (49.8)
64.1 (53.7)
BCS
Baseline
Follow up
72
27
44.3
35.2 (46.2)
(78.7)
LIG
Baseline
44
32.6 (35.3)
HIG
Follow up
36
59.5
(81.7)
Baseline
40
28.2 (32.5)
Follow up
36
53.6
(41.0)
C
Baseline
75
49.8
(59.7)
178
Cancer type
p
0.23
0.20
0.23
0.20
difference
Group difference
p
0.59
0.59
0.028d
0.028d
0.028d
Hours per week of
moderate intensity
M (SD)
3.2 (6.0)
4.6 (5.3)
2.9 (6.2)
4.8 (16.0)
3.0 (5.4)
6.0 (14.4)
1.8 (3.5)
3.3 (3.9)
3.8 (7.4)
physical activity
Cancer type
p
0.69
0.97
0.69
0.97
difference
Group difference
p
0.23
0.25
0.23
0.25
0.23
Hours per week of
vigorous intensity
M (SD)
1.7 (3.4)
3.5 (4.7)
1.2 (2.5)
2.0 (2.3)
1.2 (2.2)
2.6 (3.9)
0.8 (1.8)
3.3 (4.1)
2.1 (3.9)
physical activity
Cancer type
p
0.31
0.15
0.31
0.15
difference
Group difference
p
0.07
0.50
0.07
0.50
0.07
Note: LIG = lower intensity group; HIG = higher intensity group; C = control group. Significant (p < 0.05) group differences in bold. d No significant post-hoc
differences between groups.
Table 42
Physical Activity Levels at Baseline and Follow Up as Measured by IPAQ, with Outliers Removed
Outcome
Statistic
n
Baseline
84
PCS
Follow up
45
BCS
Baseline
Follow up
71
26
30.1
31.5 (34.8)
(27.6)
LIG
Baseline
44
HIG
Follow up
35
49.4
(55.4)
Baseline
40
179
MET hours per week
M (SD)
36.4 (38.2) 64.1 (53.7)
32.6 (35.3)
28.2 (32.5)
without outliers
Cancer type
p
0.28
0.28
0.005
0.005
difference
Group difference
p
0.22
0.70
0.22
Hours per week of
moderate intensity
M (SD)
2.5 (4.5)
4.6 (5.3)
2.4 (4.7)
1.7 (2.6)
3.0 (5.4)
3.7 (5.5)
1.8 (3.5)
physical activity
Cancer type
p
0.85
0.85
0.014
0.014
difference
Group difference
p
0.47
0.79
0.47
Hours per week of
vigorous intensity
M (SD)
1.4 (3.1)
3.5 (4.7)
1.0 (1.5)
1.9 (2.3)
1.2 (2.2)
2.6 (3.9)
0.8 (1.8)
physical activity
Cancer type
p
0.26
0.13
0.26
0.13
difference
Group difference
p
0.26
0.45
0.26
Note: LIG = lower intensity group; HIG = higher intensity group; C = control group. Significant (p < 0.05) group differences in bold.
Follow up
36
53.6
(41.0)
C
Baseline
71
38.9
(39.7)
0.70
0.22
3.3 (3.9)
2.5 (4.6)
0.79
0.47
3.3 (4.1)
1.6 (3.0)
0.45
0.26
5.6.1 Physical activity barriers and choices.
At the follow-up assessment, the participants reported the barriers to their ability
to complete their exercise routines, as well as the types of physical activity they had
been performing (Table 43). The most common reason for decreasing physical activity
was a return to work or an increase in time at work. Many of the participants, especially
those who had completed treatment within six months of enrolling, took extended leave
from work or reduced their weekly hours at work to help them recover and to participate
in the intervention program. By the time of the follow up, many of these people had
returned to full-time employment. There were no differences between the exercise
intensity groups (p = 0.75) or cancer types (p = 0.90) in the reasons given for a decrease
in physical activity. Walking was the most commonly performed activity, followed by
home- or community-based gym training (resistance training and cardio machines). The
Pearson chi-square tests indicated no differences between the groups (p = 0.91) or
cancer types (p = 0.24) for the activities performed.
Table 43
Reasons for Decreasing Physical Activity and Types of Activities Performed Among
Follow-up Participants (n = 72)
Reasons for decreasing physical activity
Work
Injury
Surgery
Pain
Complications related to cancer
Fatigue
Holiday
Taking care of family
Illness
Not motivated
Heat
Lack of money
Moving house
N (%)
14 (17)
11 (13)
10 (12)
9 (11)
8 (9)
8 (9)
7 (8)
7 (8)
6 (7)
2 (2)
1 (1)
1 (1)
1 (1)
180
Types of activities performed
Walking
Gym
Physical labour/gardening
Golf
Cycling
Swimming
Yoga
Dance
Hydrotherapy class
Training for a marathon
Physiotherapy
Rock climbing
Competitive sailing
N (%)
37 (31)
31 (26)
12 (10)
8 (7)
7 (6)
6 (5)
4 (3)
3 (3)
3 (3)
2 (2)
2 (2)
1 (1)
1 (1)
5.7 Summary
To summarise the results, the research questions are answered in the following
sections.
1. Is a group exercise and SGP intervention feasible and acceptable to breast and
prostate cancer survivors?
In Chapter 3, the pilot study used mixed methods to determine that the
intervention was feasible and acceptable to breast and prostate cancer survivors. This
was evidenced from the participants’ positive responses during the group feedback
interviews and by the high attendance rates for both components of the intervention.
The main themes to emerge from the narrative feedback were:

an opportunity to explore and redefine self-identity

support to succeed, despite prior failures

the importance of exercise variety

the value that the combined exercise and counselling model offered the
participants

changing perceptions of counselling

the importance of participating in the program as a group

the importance of maintaining exercise behaviours.
2. Are breast and prostate cancer survivors able to adhere to and comply with an
exercise program at an intensity of 75 to 80% VO2peak and 65 to 80% 1RM?
The breast and prostate cancer survivors tolerated the higher intensity exercise
program, as evidenced by a 90% attendance rate and no adverse events occurring, such
as injury or lymphoedema. The participants complied fully with the higher intensity
resistance training prescription. However, the compliance to the aerobic exercise
prescription of the HIG (90%) was not as high as the LIG (97%). Further exploration
181
revealed that the participants exercised at a wide range of aerobic exercise intensities,
regardless of intervention assignment. On average, the LIG exercised at 61% VO2peak
and 50 to 65% 1RM, while the HIG exercised at 70% VO2peak and 65 to 80% 1RM.
3. Are there differences in the physiological and psychological responses between
cancer survivors participating in an exercise program at 60 to 65% VO2peak and
50 to 65% 1RM, 75 to 80% VO2peak and 65 to 80% 1RM, or usual care?
Most of the physiological outcomes improved between baseline and postintervention, yet few psychological outcomes showed improvement. The participants in
the HIG showed the greatest improvements in strength and body composition. Both
intensity groups improved VO2peak similarly, and both more than the controls. From
baseline to post-intervention, the HIG improved more than the C on BF%, VO2peak, all
three measures of muscular strength and endurance, and identified regulation (which
describes motivation to exercise in order to achieve a larger goal). The HIG also
improved significantly more than the LIG in push-ups and leg press 1RM. The LIG
improved shoulder ROM, VO2peak, core stability and identified regulation more than
the C. The participants improved their QOL equally well, regardless of group
assignment.
Fatigue levels started and remained low for all participants. These results
indicate that performing aerobic exercises at either the higher or lower intensity leads to
similar improvements in VO2peak, which were not achieved with usual care. The results
also indicated that performing resistance exercise at 65 to 80% 1RM was significantly
better for improving muscular strength and endurance than using 50 to 65% 1RM or
undergoing usual care. Lastly, there were no observable added benefits for QOL or
fatigue from participating in this exercise and SGP intervention instead of usual care.
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4. Are there differences in the sustainability of the physiological and psychological
parameters at follow up between the breast and prostate cancer survivors who
completed the program exercising at a higher intensity compared to those who
exercised at a lower intensity?
The higher intensity exercise allowed for greater maintenance of some
physiological and exercise motivation outcomes than did the lower intensity exercise.
At the follow-up assessment, the HIG maintained their lower back/hamstring flexibility
and VO2peak, while the performance scores for the LIG reduced. There were no
differences between the groups for maintenance of any other physiological variable.
Overall, the participants maintained their weight, flexibility, upper body muscular
endurance and lower body strength, while regressing on core stability. There were also
no significant differences between the groups for maintenance of QOL, with the
participants reporting levels similar to post-intervention.
There were significant differences between the LIG and HIG for change from
post-intervention to follow up on overall exercise motivation. This was also true for
most of the components—most importantly for the subscales that measured autonomous
motivation. The LIG decreased their autonomous motivation and increased their
external motivation, which led to a decrease in overall exercise motivation. In contrast,
the HIG increased their autonomous motivation, while decreasing their external
motivation, which led to an increase in overall exercise motivation. Lastly, changes in
overall fatigue and three of the fatigue subscales were no different between the groups,
with only change in cognitive fatigue reaching significance. On cognitive fatigue, the
HIG maintained not feeling fatigued, while the LIG returned towards moderate fatigue.
183
program adherence between the breast and prostate cancer survivors to the same
group exercise and SGP intervention?
Compliance and attendance to both the exercise and SGP components were
similar for both cancer types. The breast cancer survivors improved their upper body
muscular endurance and lower body strength by a greater amount than did the prostate
cancer survivors. There were significant interactions between the group and cancer type
on the emotional wellbeing subscale of the FACT-G and the introjected regulations
subscale of the BREQ-2. In both cases, the LIG had the greatest increase among the
prostate cancer survivors, while the HIG had the greatest increase among the breast
cancer survivors. There were no other differences between cancer types on changes in
response to the intervention. At the follow-up assessment, the changes on all outcome
measures were similar between the cancer types. These results indicated that the breast
and prostate cancer survivors had similar short- and long-term responses to the group
exercise and SGP intervention, although the breast cancer survivors may have benefited
more from the structured resistance training than did the prostate cancer survivors.
6. Are there differences in physical activity levels four months after a short-term
intervention between the breast and prostate cancer survivors who completed the
program exercising at a higher intensity, compared to those who exercised at a
lower intensity?
The exercise intensity assignment did not appear to affect the physical activity
levels at follow up, with both groups engaging in a very high level of physical activity
four months post-intervention. However, the breast cancer survivors reported fewer
hours per week of moderate intensity physical activity, and therefore total physical
184
activity levels, than did the prostate cancer survivors, when the outliers were removed
from the analyses.
185
Chapter 6: Discussion
6.1 Key Findings
As a product of this research, six key findings of relevance to breast and prostate
cancer rehabilitation were made:
1. Both breast and prostate cancer survivors found the intervention design,
which combined group exercise and SGP, to be acceptable and feasible. In
particular, the participants found that exercising together helped create the
group bonding necessary to facilitate trust and mutual aid in the group
counselling sessions.
2. The participants found it difficult to comply with their assigned aerobic
exercise intensity, especially those assigned to a higher intensity. In general,
the participants seemed to self-select their aerobic exercise intensity. The
participants found it much easier to comply with the resistance training
intensity prescription.
3. The group exercise and SGP intervention was effective at improving some
physiological outcomes, but it did not affect QOL or fatigue. VO2peak and
exercise motivation improved for the intervention participants, regardless of
the exercise intensity. The higher intensity exercise conferred greater
improvements in body composition and muscular strength and endurance
compared to the control and lower intensity exercise.
4. Participating in the higher intensity exercise led to more sustained gains in
VO2peak and exercise motivation over the four-month sustainability period
than did lower intensity exercise.
186
5. Overall, there were few differences between the males and females. The
breast cancer survivors improved on push-ups and leg press 1RM to a greater
extent than did the prostate cancer survivors.
6. The exercise intensity did not modulate the physical activity levels at follow
up. The breast cancer survivors reported fewer hours per week of moderate
intensity physical activity, and therefore total physical activity levels, than
did the prostate cancer survivors.
6.2 Intervention Design
The participants enjoyed and regularly attended the intervention. Both the breast
and prostate cancer survivors described how combining the group exercise and SGP
interventions provided more value to their experience. However, although the
intervention members fully participated in the exercise program, many had difficulty
complying with their aerobic exercise prescription despite wearing HR monitors and
being encouraged by the researcher to maintain their target HR.
6.2.1 Participant recruitment and attendance.
The recruitment of participants was difficult, but was similar to other exercise
oncology research projects in the same metropolitan area, which ranged between 44%
and 59% of participants assessed for eligibility (Galvao et al., 2010; Milne et al.,
2008a). Program attendance and retention rates were excellent (Table 20 and Figure 2),
in line with or better than other studies, which reported between 60% and 94% (De
Backer et al., 2008; Galvao, Taaffe, Spry, Joseph & Newton, 2010; May et al., 2009;
Milne et al., 2008a). The results indicated that the people who did enrol in the study
valued the intervention and were motivated to attend the majority of sessions and
complete the program.
187
6.2.2 Acceptance.
The results of the pilot study indicated that the group exercise and SGP
intervention was feasible and acceptable to both the breast and prostate cancer
survivors. The group feedback interviews highlighted that, despite their initial
reluctance to undertake counselling, the men fully embraced and participated in the SGP
sessions. All the participants described how they bonded during the exercise sessions,
which created feelings of trust and mutual aid among the members. This group cohesion
encouraged them to engage more fully in discussions and sharing with each other.
Further, in both the pilot and main study, the participants attended over 80% of both the
exercise and SGP sessions. These were excellent results, especially for the prostate
cancer survivors. As discussed in the pilot study chapter, the prior literature has found
that men, regardless of having cancer, are reluctant to participate in mental health
services due to feelings of stigma or disinterest (Carmack Taylor et al., 2006; Eakin &
Strycker, 2001; Kaplan, 2008; Krizek et al., 1999; Nekolaichuk et al., 2011; Petersson et
al., 2000; Sherman et al., 2007; Steginga et al., 2008). The participants deemed exercise
an effective means for facilitating counselling sessions and increasing active
participation in SGP among prostate cancer survivors.
6.2.3 Compliance.
The main study focused on the physiological and psychological response of a
higher intensity exercise program, compared to a lower intensity exercise program. The
higher intensity exercise was safe for the participants and did not lead to any injuries or
worsening of symptoms, such as lymphoedema. The breast and prostate cancer
survivors tolerated both lower and higher intensity aerobic and resistance exercise, as
exhibited by high attendance and compliance rates to both programs. The aerobic
exercise intensity compliance rates of both groups were higher than the 70 to 77%
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compliance rates reported in other studies that examined high intensity exercise in
cancer survivors (Adamsen et al., 2009; De Backer et al., 2008; Quist et al., 2006).
However, the compliance rates were lower among the HIG members than the LIG
members. The planned targeted difference in aerobic intensity between the LIG and
HIG was initially 15%; however, the actual difference was only 9%. The lower intensity
level at which the HIG worked may have accounted for the similar levels of
improvement in VO2peak from baseline to post-intervention between these two groups.
A number of factors may have confounded the aerobic compliance of the
participants. Aerobic exercise was performed at a continuous intensity, ranging in
duration from three to 22 minutes, although most aerobic exercise bouts lasted around
10 minutes. Performing aerobic exercise as intervals of 20 seconds, rather than trying to
achieve and maintain a high target aerobic intensity, may improve a participant’s ability
to exercise at a higher intensity. For example, a popular training protocol studied by
Tabata et al. (1996) prescribed three to four minute intervals, alternating between 20
seconds at 170% of VO2max and 10 seconds of rest. Additionally, research has shown
that high intensity interval training is perceived as being more enjoyable and increases
exercise motivation more so than moderate intensity continuous exercise (Bartlett et al.,
2011). In the present study, various interval training protocols were implemented during
four of the exercise sessions. However, to provide participants with a wide variety of
exercise modes, these were not exclusively used.
Exploratory analyses of the aerobic exercise intensity compliance data indicated
that the participants self-selected their intensity level, regardless of prescription, with
many participants exercising at the level prescribed for the other intensity group. The
participants did not have a choice of exercise group, which may have made the
experience less pleasurable (Lind, Ekkekakis & Vazou, 2008; Parfitt et al., 2000; Parfitt
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& Hughes, 2009). Several observational studies have described how personality affects
adherence to exercise and intensity level of exercise, regardless of prescription (Milne et
al., 2007; Parfitt et al., 2000; Parfitt & Hughes, 2009; Rhodes et al., 2001; Ryan et al.,
1997).
Vazou-Ekkekakis and Ekkekakis (2009) found that dictating exercise intensity
to people, even if it is identical to a previously self-selected exercise intensity, reduces
feelings of interest and enjoyment. Likewise, negative feelings are often associated with
non-preferred exercise intensities (Parfitt & Hughes, 2009). Conversely, participants
self-select the intensity of exercise they associate with high levels of positive wellbeing
and low levels of psychological distress (Parfitt et al., 2000). Giving people choice and
control of their exercise intensity is more likely to increase interest in exercising and
adherence, while having all variables prescribed may create an adverse psychological
affective response (Parfitt & Hughes, 2009; Thorsen et al., 2008; Vazou-Ekkekakis &
Ekkekakis, 2009).
This could have been the case in the present study. The innate drive to self-select
exercise intensity to create a pleasurable experience may partly explain why it was
difficult for some participants in the HIG to maintain their prescribed higher exercise
intensity, and why some participants in the LIG sought to exercise at a higher intensity.
The dual-mode theory explains why participants in the HIG complied with their aerobic
exercise prescription less strictly than did the LIG members. While cognitive control of
feelings may allow some people to interpret high intensity exercise as pleasurable,
research has found that, for almost every individual, there is a threshold intensity at and
above which exercise becomes displeasurable (Parfitt & Hughes, 2009). Therefore, it is
likely that more of the HIG than LIG participants were prescribed an exercise intensity
that they found unpleasant because of it being too intense.
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When designing the study, it was decided to blind the participants to the
existence of the different exercise intensity intervention groups. This was done to
reduce the risk of people exercising at the level of the group to which they would have
preferred to be assigned (Bill-Axelson, Christensson, Carlsson, Norlen & Holmberg,
2008; Moher et al., 2010). As Schulz et al. (2002) wrote, when a study compares
multiple interventions, participants’ ‘knowledge of the intervention received can affect
the psychological or physical responses of the participants’ (p. 255). Additionally, not
blinding participants to the trial arm assignment may have encouraged a greater dropout rate from the participants not assigned to their preferred arm (Avenell et al., 2004).
Further, potential participants may have been unwilling to enrol in a study in
which there was a chance they could be randomised to a control group, thus creating
selection bias of the sample. In the present study, the control participants often chose
not to enrol in the intervention, but were willing to undergo the assessments. It is
possible that, had the groups not been blinded and were aware of their intensity
assignment, they may have been more diligent in adhering to their prescribed level.
Some research has found greater participant compliance in open trial designs, rather
than blinded designs, although these studies recognised that removing the blinding does
create a threat to internal validity (Avenell et al., 2004).
Another potential confounder of aerobic compliance was the poor reliability of
the Team2 Polar system. The HR monitors would sometimes not display a realistic HR,
or any HR, for the participants, despite proper use of the equipment. Anecdotally, the
participants reported that the unreliability of the equipment was frustrating and made
them pay less attention to the HR monitors throughout the intervention (they gave up on
their use). The Team2 Polar system is designed for use outdoors on open training fields
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with little obstruction. It is likely that the cement columns, exercise machines and
interference of other electronics within the gym contributed to the poor signal reception.
In contrast to the aerobic exercise compliance, the participants had no difficulty
performing the high intensity resistance training prescription. This was probably due to
the greater control the researcher had over the resistance training loads than the aerobic
training loads. Monitoring the resistance training was easier than monitoring the HR
because the resistance level (kg) was set and maintained for a predetermined number of
repetitions. In contrast, during aerobic exercise, HR has to be continuously monitored
and adjustments made to pacing.
6.3 Effectiveness of Intervention and Intensity Differences
The intervention helped the participants improve many physiological, but few
psychological, outcomes, and some gains were maintained for over four months. The
higher intensity exercise provided greater physiological benefits when the participants
adhered to the prescription. The exercise intensity did not modulate short-term
psychological changes, although the HIG sustained their improvements in exercise
motivation, while the LIG did not.
6.3.1 Physiological outcomes.
Overall, the higher intensity exercise provided more sustained improvements in
cardiorespiratory fitness, while the lower intensity exercise did not. Both groups
improved and maintained both upper and lower body flexibility. The higher intensity
exercise resulted in larger gains in strength and body composition immediately after the
intervention; however, at follow up, the exercise groups reported similar changes. Both
groups maintained or exhibited small improvements in body composition and small
losses in strength from post-intervention to follow up.
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6.3.1.1 Body composition.
Participating in the higher intensity exercise produced a significant and sustained
reduction in BF%, while the lower intensity exercise provided no greater change than
usual care. These results illustrate the well-documented importance of performing
higher intensity aerobic and resistance exercise simultaneously to make significant
improvements in body composition (Friedenreich et al., 2011; Visovsky, 2006). The
decrease in BF% achieved by the HIG was similar to the results of the study by Quist et
al. (2006), which also prescribed high intensity aerobic (75 to 80% VO2max) and
resistance (85 to 95% 1RM) exercise. Previously, many studies have used only low to
moderate intensity exercise and/or only aerobic exercise or resistance exercise (Galvao
et al., 2006; Keogh & MacLeod, 2012; Knobf et al., 2008). These studies’ results
revealed only small decreases or even increases in body fat among the cancer survivors
who participated in lower intensity and/or single modal exercise interventions.
The present study’s findings are important because being obese greatly increases
all-cause and cancer-specific mortality risk, while reductions in body fat significantly
improve survival (Dal Maso et al., 2008; Ewertz et al., 2011; Magne et al., 2011;
Reeves et al., 2007). High intensity aerobic and resistance exercise is necessary to make
significant improvements in body composition for healthy individuals (Boutcher, 2011;
Tambalis et al., 2009). Therefore, if higher intensity exercise also allows cancer
survivors to maintain an optimal body composition, while lower intensity exercise does
not, it is likely that higher intensities will reduce their mortality risk.
One surprising aspect of this result was that the significant reduction in body fat
was achieved with no attention being paid to diet or food intake. Research has
repeatedly shown that exercise and diet modification combinations to improve body
composition are superior to using either method alone (Pekmezi & Demark-Wahnefried,
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2011). The HIG achieved similar reductions in body fat as the other breast cancer
survivors who participated in a six-month combined exercise and diet intervention
(Greenlee et al., 2013). Monitoring or influencing diet was beyond the scope of this
study, but it is possible that the participants spontaneously engaged in dietary
behaviours that may have influenced the results.
6.3.1.2 Flexibility.
The results indicated that lower intensity exercise improved shoulder flexibility
compared to usual care, but that the intervention did not improve hamstring or lower
back flexibility. For breast cancer survivors, restoring shoulder ROM is of great
importance after surgery and radiotherapy (Box et al., 2002b; Kuehn et al., 2000).
However, as the participants, on average, already had good upper body flexibility, the
greater benefits of the lower intensity exercise should be interpreted with caution. The
greater improvement was likely due to the LIG simply starting with the lowest shoulder
ROM at baseline.
6.3.1.3 Cardiorespiratory fitness.
Both intervention arms improved VO2peak to a similar extent when compared to
the control group. This was not as hypothesised, but was unsurprising because the
analysis of the aerobic prescription compliance revealed that the intervention arms were
exercising at a difference of only 9% of VO2peak, not the planned 15%. These results
indicated that exercising between 61% and 70% VO2peak elicited similar changes in
cardiorespiratory fitness for breast and prostate cancer survivors. It is possible that a
difference greater than 9% in relative aerobic exercise intensity may be needed to detect
a significant difference in cardiorespiratory adaptation during an eight-week exercise
intervention.
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Most of the intervention participants met the clinically meaningful threshold of
2.1 mL/kg/min for improving VO2peak (Tolentino et al., 2010; Tosti et al., 2011). Tosti
et al. (2011) found that breast cancer survivors who had finished treatment within six
months of testing had an estimated VO2max 2.1 mL/kg/min lower than healthy women
matched for age and BMI. This result indicates that an increase of 2.1 mL/kg/min was
the minimum amount of improvement needed to restore cancer survivors to prediagnosis VO2peak levels.
The gains in VO2peak experienced by the participants in the present study were
comparable to or lower than those results reported in other studies involving cancer
survivors (Courneya et al., 2003b; De Backer et al., 2007; Galvao et al., 2010; Jones et
al., 2011; Milne et al., 2008a; Quist et al., 2006). In many cases, this may be attributed
to longer intervention duration or higher training intensities of the other studies. For
example, the study by Quist et al. (2006) reported greater improvements in VO2peak
after only six weeks. The difference in this study was that the participants were
prescribed truly high intensity aerobic exercise, at 85 to 95% HRmax. Training at the
highest end of exercise intensities may result in improvements in cardiovascular
capacity that are more immediate and responsive.
An important result of the follow-up assessment was that the HIG maintained
their VO2peak, while the LIG returned to pre-intervention levels. There is some
evidence that, by following a high intensity exercise program, VO2peak can be
maintained with as little as one session per week (Madsen, Pedersen, Djurhuus &
Klitgaard, 1993). Mechanisms that allow for maintained performance and VO2peak,
despite a reduction in physical activity, include sustained elevations of muscle oxidative
capacity, such as higher muscle content of cytochrome c oxidase subunit 4 and GLUT4
transporter proteins (Burgomaster et al., 2007). As VO2peak has been identified as the
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best predictor of survival (Blair et al., 1996; Kodama et al., 2009), these results suggest
that higher intensity exercise may provide a more sustainable and greater benefit to
cancer survivor longevity than lower intensity exercise, by allowing people to maintain
a higher level of cardiorespiratory fitness.
While the groups had similar levels of physical activity at follow up, the LIG
was completing almost double the volume of moderate intensity exercise, with slightly
lower volumes of vigorous intensity exercise, compared to the HIG. As noted
previously, higher intensity exercise provides greater health benefits than does moderate
intensity exercise, including improved VO2peak (Swain & Franklin, 2006). The higher
intensity physical activity undertaken by the HIG post-intervention may explain why
they maintained their VO2peak, while the LIG lost their aerobic fitness gains.
6.3.1.4 Muscular strength and endurance.
The results of the present study indicate that higher intensity resistance exercise
is more effective in providing a clinically meaningful improvement in muscular strength
than lower intensity exercise (Alt et al., 2011; Harrington et al., 2011; Merchant et al.,
2008; Tisdale, 1999). This is unsurprising because the high amount of control in
resistance training allows for a simple and effective progressive overload to achieve
targeted improvements (ACSM, 2009). The higher intensity resistance training probably
contributed to the greater decrease in body fat because fat-free mass (such as muscle
mass) is the best determinant of basal metabolic rate (Ravussin, Lillioja, Anderson,
Christin & Bogardus, 1986). Consequently, increases in muscle mass often occur
simultaneously to decreases in fat mass (Goodpaster et al., 2000; Santanasto et al.,
2011).
The improvements in muscular strength and endurance at the post-intervention
of the LIG were similar or lower to that which other research studies have
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demonstrated, while the HIG had similar or greater improvements (De Backer et al.,
2007; Galvao et al., 2006; Galvao et al., 2010; Schneider et al., 2007; Segal et al.,
2003). Muscular strength and endurance were generally maintained by both intensity
groups from post-intervention to follow up. The similarity in strength outcomes may be
attributable to the groups performing similar types of physical activity during the
sustainability period and not being structured into higher or lower intensity exercise
routines.
6.3.2 Psychological outcomes.
There were no benefits of the intervention over usual care for QOL or fatigue.
The participants in both intervention groups became more motivated to exercise;
however, only those in the high intensity group remained highly motivated at the
follow-up assessment. Those in the lower intensity group lost their extra motivation
across the sustainability phase.
Participating in the intervention, regardless of group, made no difference to
QOL. This may be due to the participants already having relatively high QOL scores
and due to the short timeframe of the intervention. Ferrer et al. (2011) demonstrated that
intensity did not mediate QOL improvements in short-term exercise interventions. The
failure to detect any differences between both intervention arms and the control group
was surprising because the intervention participants made improvements in most
physiological measures, compared to the control group. Improvements in such
outcomes—particularly cardiorespiratory fitness—are often associated with improved
QOL (Herrero et al., 2006; Silva Neto et al., 2012; Sloan, Sawada, Martin, Church &
Blair, 2009).
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The baseline FACT-G scores for all groups started higher than the average
values for cancer survivors and the general population (Brucker et al., 2005). This was
unexpected because previous studies have shown that, even one year post-treatment,
many cancer survivors still report QOL scores lower than the general population
(Bowen et al., 2007; Lee et al., 2011a). Several factors may help explain why the
participants in the present study rated their QOL so high at baseline. First, the
participants in all three groups reported high physical activity levels at baseline,
reporting over nine times the minimum PAG (Physical Activity Guidelines Advisory
Committee, 2008). Higher levels of physical activity are correlated with higher QOL
scores (Chen et al., 2009; Faul et al., 2011; Ferrer et al., 2011). Therefore, it is not
surprising that the control group had the highest baseline FACT-G scores on average,
given that they also had the highest baseline physical activity levels.
Similarities between the intervention and control participants for physical
activity levels and QOL scores also occurred in a Scottish study (Mutrie et al., 2007;
Mutrie et al., 2012). In the longest follow-up study conducted in exercise oncology,
breast cancer survivors were randomised to three months of either a group exercise
intervention or usual care control, and were followed up at six months and five years
after enrolment (Mutrie et al., 2012). At all assessments, the control and intervention
participants maintained similar physical activity levels and QOL scores over the five
years.
Another possibility is that the present participants may have felt that they
restored whatever loss to QOL they experienced from cancer treatment by the time they
enrolled in the study, rather than still feeling like their QOL was impaired, as many
cancer survivors do (Bowen et al., 2007; Lee et al., 2011a). Studies have documented
that QOL improves during the first year post–cancer treatment as participants learn to
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cope with their circumstances (Ganz et al., 1992; King et al., 2000; Lev et al., 2009; Lin
et al., 2012; Moyer, 1997; Schover et al., 1995). Further, the mean age of the
participants in the present study (62 years old) placed them in the range of cancer
survivors who seem to fare best in terms of maintaining or regaining their QOL (Ganz
et al., 2003; Schover et al., 1995; Zebrack et al., 2008). This may have also contributed
to their coping ability and subsequently high baseline QOL scores.
6.3.2.2 Exercise motivation.
It appeared that exercise motivation improved during the intervention, regardless
of exercise intensity. The intervention participants increased their motivation to achieve
personal goals, compared to the control participants. This could be due to the goalsetting activities included in the intervention as part of the TTM delivery (Edmunds,
Ntoumanis & Duda, 2008). As seen in Table 34, there were trends for this same pattern
to be followed for exercise enjoyment and motivation to achieve health benefits. These
results suggest that the present intervention contributed to increased autonomous
motivation for breast and prostate cancer survivors to exercise. Possible explanations for
the lack of difference in motivation levels between the intensity arms are that both
received behavioural change strategies and social support via the other members of their
exercise groups.
Similar to a study by Milne et al. (2008b), the present study did not empirically
measure the program features that increased participant exercise motivation. However,
narrative reports from the participants in the pilot and main studies provided some
insights regarding what intervention features increase exercise motivation. As
autonomous motivation is the key to long-term exercise adoption, it is important to
determine what intervention factors contribute to maximising cancer survivors’
motivation (Teixeira et al., 2012).
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During the pilot and main phases of the present research, the participants often
commented that the variety of exercise activities made the program more enjoyable than
if it had been one repetitive exercise routine. These narrative reports were confirmed by
measured increases on the BREQ-2 for enjoyment of exercise. Many participants stated
that they were motivated to attend each session to see what new surprise was awaiting
them. These anecdotes align with the results of a mixed-methods study that examined
the ways exercise program structure can influence motivation (Motschiedler & Coutts,
2010).
Motschiedler and Coutts (2010) found that an exercise program that presented a
variety of workouts was more enjoyable for participants than a more regimented
program with less variety. Enjoyment is key to autonomous exercise motivation
(Ingledew & Markland, 2008); thus, providing a more enjoyable exercise program
through presenting a variety of workouts seems to be a good strategy for improving
participants’ autonomous motivation. Participants in the present study also stated that
group interaction was a key motivating factor for them. In support of this anecdote, they
scored their social wellbeing as high. Group support has been repeatedly highlighted in
other research as an important contributor for improving exercise motivation and
adherence (McAuley, Jerome, Elavsky, Marquez & Ramsey, 2003; Rogers et al., 2008).
The most important psychological outcome from the follow-up assessment was
that the HIG maintained their autonomous and overall motivation to exercise, while the
LIG returned to their pre-intervention levels. The specific question that was rated the
highest at post-intervention and increased the most from baseline to post-intervention
was ‘I enjoy my exercise sessions’. From post-intervention to the follow-up assessment,
the LIG decreased their intrinsic regulation, and, interestingly, their enjoyment declined
the most significantly of all the factors contributing to this subscale. These results
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indicated that, while both intensity groups perceived their exercise as enjoyable when
participating in the intervention, only the HIG maintained this perception.
Many people find higher intensity exercise to be more enjoyable than lower
intensity exercise (Bartlett et al., 2011; Duncan et al., 2010). One reason for this is that
many people enjoy the challenge (Teixeira, Carraca, Markland, Silva & Ryan, 2012).
One should interpret the success of the HIG for maintaining their exercise motivation
with caution because the follow-up period was relatively short (four months postintervention). A longitudinal study conducted by Emery et al. (2009) showed that cancer
survivors continue to exercise for 18 months post-intervention, but that by five years
post-intervention, they regress to below baseline physical activity levels. As Courneya
et al. (2006) wrote, ‘exercise adherence is an ongoing challenge that never becomes
easy even for the most dedicated breast cancer survivor’ (p. 263).
6.3.2.3 Fatigue.
Participating in exercise has consistently been shown to reduce fatigue among
cancer survivors (Jacobsen et al., 2007; Keogh & MacLeod, 2012; McNeely et al.,
2006). However, in the present study, because the participants did not feel fatigued at
baseline, they had minimal potential to improve. Consequently, the present study was
unable to determine whether exercise intensity makes a significant difference in the
degree of relieving fatigue among cancer survivors. The study reported by Monga et al.
(2007) exhibited the same phenomenon, where the prostate cancer survivors started with
a fatigue score of 2.4 points (mild fatigue) and decreased by 1.6 points on the PFS. A
positive outcome of the present study was that the higher intensity exercise did not
increase the feelings of fatigue among the breast and prostate cancer survivors. As the
average time since treatment completion was approximately one year for the present
participants and the baseline fatigue scores were low, it is reasonable to assume that
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most of the participants had already resolved their fatigue naturally, and that few had
developed clinically diagnosed post-cancer fatigue (Cho et al., 2012; Garabeli Cavalli
Kluthcovsky et al., 2012). One could also speculate that people with post-cancer fatigue
are also unlikely to sign up for an exercise study.
6.4 Gender Differences in Intervention Response
The breast and prostate cancer survivors, regardless of the intensity group, had
similar physiological and psychological responses to the intervention and maintenance
of these changes. The only meaningful differences were for upper body muscular
endurance, lower body strength and cancer-specific QOL changes during the
intervention. On both physiological measures, while the prostate cancer survivors
experienced significant improvements, the improvements of the breast cancer survivors
almost doubled those of the corresponding prostate cancer survivors. There are two
possible explanations for the difference in response between the cancer types on pushups and leg press 1RM. First, the breast cancer survivors had a lower baseline leg press
1RM and could perform fewer push-ups than the prostate cancer survivors, indicating
that the breast cancer survivors had more potential to improve (Peterson et al., 2005). A
second possible explanation is that the cancer types used different test protocols
(Kraemer & Fry, 1995). Following the ACSM (2006) guidelines on push-up tests for
men and women, the breast cancer survivors performed them from their knees, while
the prostate cancer survivors performed them from their toes. Many of the prostate
cancer survivors could not perform push-ups from their toes, and, during the
intervention, performed them from their knees.
Likewise, the breast cancer survivors were shorter on average than the prostate
cancer survivors. On the particular machine used to test leg press 1RM, being shorter
gave them a mechanical advantage because the shorter participants started in a more
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favourable length-tension relationship for their quadriceps (Kraemer & Fry, 1995). For
the only equal test of muscular strength endurance—the plank test—there was no
difference in improvement between the cancer types. Even though there were
statistically significant interactions between cancer type and group on one subscale each
from two questionnaires, these interactions were not clinically meaningful (Milne et al.,
2008a; Milne et al., 2008c; Webster et al., 2003).
While there was no difference between cancer types on change in general QOL,
exercise intensity seemed to affect breast cancer–specific, but not prostate cancer–
specific, QOL concerns. Body image has been identified as a main predictor of QOL
among breast cancer survivors, and is addressed in the additional concerns section of the
FACT-B (Brady et al., 1997; Ganz et al., 1992; Ganz, Schag & Cheng, 1990; Schover et
al., 1995). Of the objective measures recorded in this study, body fat most likely
contributed to body image. Considering the HIG had the greatest decrease in BF% from
baseline to post-intervention, it was unsurprising that this group also had the greatest
improvement in their feelings about their body composition and appearance. The LIG
group did not improve QOL compared to the controls. These results indicated that
higher intensity exercise was needed to make measurable improvements in breast
cancer–specific concerns about QOL.
Conversely, among the prostate cancer survivors, the group exercise and SGP
intervention did not improve their specific QOL concerns. One possible explanation for
this, as identified in the pilot study, was that sexual dysfunction was a main issue related
to QOL (Sanda et al., 2008). Sexual dysfunction affects many physical, psychological
and social aspects of prostate cancer survivors’ QOL (Esper et al., 1997; Sanda et al.,
2008). Several questions on the FACT-P focus on men’s ability to have and maintain an
erection, their satisfaction with their sex life, and how changes in sexual prowess affect
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their self-image (Esper et al., 1997) (see Appendix C for a copy of the FACT-P). For
these specific questions, the majority of men reported a lack of sexual function, which
caused them distress and saw no improvement over time. Improving sexual function
was beyond the scope of the present intervention, despite the attention paid to the pelvic
floor muscles (Prota et al., 2012). To date, no research has explained how short- or
long-term general exercise may affect the sexual abilities of prostate cancer survivors.
The similarity between the cancer types was expected because a range of clinical
trials, reviews and meta-analyses have indicated that breast and prostate cancer
survivors respond equally well to exercise stimuli on both physiological and
psychosocial measures (Blanchard et al., 2004; Courneya, 2003; De Backer et al., 2007;
Egan et al., 2013; Fong et al., 2012; Hamer et al., 2009; Quist et al., 2006; Schmitz et
al., 2010; Schneider et al., 2007). Of particular interest is the study by De Backer et al.
(2007), which used high intensity exercise in male and female cancer survivors and
found no significant differences between genders on any changes in outcome measures.
Likewise, Courneya et al. (2003a) found no significant differences between cancer types
on change in global QOL outcomes.
More consistent with the present study’s results for strength and cancer-specific
QOL are studies that show differences between genders or cancer types for the effect of
physical activity on risks of cancer diagnosis, development of CVD and acute
immunological response (Friedenreich et al., 2010; Sattelmair et al., 2011; Stupka et al.,
2000). For example, regular lifetime physical activity may provide around a 20%
reduction in the risk of developing colon, breast or prostate cancer, but there are
inconsistent findings regarding the benefit for reducing the risk of ovarian cancer.
Additionally, just between breast and prostate cancer, there seems to be a more
protective effect of physical activity against breast, rather than prostate, cancer
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(Friedenreich et al., 2010). Together, these results indicate that, while exercise seems to
help most cancer survivors both before and after cancer diagnoses, the benefits and
pathways of physiological adaptation and specific QOL improvements may be different.
More research is needed to identify whether there is a difference in the physiological
and biological mechanisms used by breast and prostate cancer survivors to adapt to
exercise.
6.5 Physical Activity Levels at Follow Up
It was interesting that, despite differing exercise motivation levels, physical
activity levels were similar at the follow up between both intervention groups. This was
probably due to the high levels of motivation and physical activity for both groups at
baseline. As other researchers have noted, the best predictor of future physical activity
levels are past physical activity levels (Rogers et al., 2008; Vallance et al., 2010). This
study’s results indicated that, even though the LIG lost some exercise motivation, they
were still sufficiently motivated to perform a high level of physical activity.
One possible explanation for the similarities between the two groups’ physical
activity levels at follow up was the design of the intervention. Both groups received the
same behavioural information—based on the TTM and focusing on behavioural
processes of change—throughout the intervention. Loprinzi et al. (2012) showed how
high usage of behavioural processes of change at the end of an exercise intervention for
breast cancer survivors significantly predicted their physical activity levels six months
later. Additionally, at the end of the present intervention, all participants were given
personalised exercise programs to continue to meet their goals. Research has
demonstrated that individualised programs, goal setting and planning are strongly
associated with better exercise maintenance (Blaney et al., 2010; Vallance et al., 2010).
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The participants consistently scored highly on the social wellbeing subscale at
all assessment points, thus indicating that they felt they had high levels of social
support. Social support is another factor that contributes to exercise maintenance
(Rogers et al., 2008; Ryan et al., 1997). While social support particular to exercise was
not tracked at follow up (for example, whether or not the participants continued to
exercise with others), the group design of the program provided a high level of support
during the intervention. Anecdotally, some participants reported that they continued to
exercise together. Future interventions could formalise this process of grouping
participants together to continue their exercise programs (Ottenbacher et al., 2012). It is
possible that this high and equal level of attention to these behavioural factors for all
intervention participants mitigated any long-term behavioural differences between the
two groups.
The activity levels of the present participants at baseline were much higher than
that which other research has reported. Most studies report ranges of only 10 to 21% of
cancer survivors meeting the PAG after treatment (Courneya et al., 2009; Emery et al.,
2009; Milne et al., 2007; Rhodes et al., 2001), with only a few reporting higher levels,
from 37 to 57% (Blanchard et al., 2003; Blanchard et al., 2008; Harrison et al., 2010).
Based on the majority of participants meeting the PAG prior to enrolment in this study,
it was unsurprising that the physical activity levels were so high at follow up. One of the
most consistent findings of Courneya and his colleagues was that previous activity
levels are one of the main and best predictors of future activity levels among cancer
survivors (Blanchard et al., 2003; Blanchard et al., 2008; Courneya et al., 2006;
Courneya et al., 2009; Milne et al., 2007; Milne et al., 2008b; Milne et al., 2008c;
Rhodes et al., 2001; Rogers et al., 2007; Rogers et al., 2008; Rogers et al., 2011;
Thorsen et al., 2008; Vallance et al., 2010).
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One important note is that, while the participants in this study were already
highly active, the present intervention was effective at increasing the physical activity
levels of previously sedentary breast and prostate cancer survivors. Previous research
has indicated that less than 20% of sedentary cancer survivors will spontaneously
become physically active after treatment (Rhodes et al., 2001). It is important that
cancer survivors increase or at least maintain their pre-diagnosis physical activity levels.
Irwin et al. (2008) revealed an almost four-fold increased risk of death if women
decreased their physical activity by three or more MET hours per week after their breast
cancer diagnosis. The design of the present intervention appeared to help sedentary
cancer survivors adopt a physically active lifestyle in the long term, which may have
decreased their mortality risk.
6.5.1 Barriers to exercise.
Barriers such as work and caring for family were the main reasons people
decreased their physical activity, as opposed to lack of motivation. Interestingly, in
observational studies, work has not been directly cited as a barrier to exercise
participation, although this could have been subsumed under ‘too busy’ or ‘time
commitment’ (Biedrzycki, 2010; Blanchard et al., 2003; Blaney et al., 2010; Courneya
et al., 2009; Emery et al., 2009; Ottenbacher et al., 2012; Rhodes et al., 2001; Rogers et
al., 2007). Rogers et al. (2011) described how barriers to exercise may have more
influence on behaviour than exercise motivation. The authors found that breast cancer
survivors decreased their barrier interference levels (how often certain barriers interfere
with exercise) at the end of participating in an exercise intervention, and that changes in
barrier interference and barrier self-efficacy (belief in one’s ability to handle barriers to
exercise) mediated follow-up physical activity levels. Interestingly, task self-efficacy
(the belief that one can successfully perform exercise) did not contribute to their model
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of factors influencing physical activity levels. Collectively, these results indicate that
removing barriers or increasing barrier self-efficacy among cancer survivors may play a
crucial role in increasing physical activity levels. Rogers and colleagues (2010)
recommend teaching cancer survivors time management techniques, such as to-do lists
and prioritization. Additionally, Rogers et al. (2010) highlighted that many of the cancer
survivors put the needs of others (most especially their family) over their own, and so
needed counselling to encourage them to take more time for their own health and
wellbeing through setting aside time to exercise.
6.6 Study Strengths
6.6.1 Novel measures.
This was one of the first studies to compare higher and lower aerobic and
resistance exercise intensities in cancer survivors. Jones et al. (2010a) commenced
research at the same time to also compare higher and lower intensity aerobic exercise in
breast cancer survivors, but, at the time of writing, had not published the results.
Previously, in exercise oncology, the only comparison of intensities was between low
and moderate intensity exercise, which showed no differences on any outcomes between
these two intensity levels (Burnham & Wilcox, 2002). The safety, tolerance and
acceptability of higher intensity exercise in the present intervention adds to the
repertoire that exercise oncologists can use to develop individualised prescriptions for
their patients, taking into account specific treatments, diagnoses, baseline fitness levels
and rehabilitation needs.
This was the first study reported to measure exercise motivation and physical
activity levels 4 months post intervention in breast and prostate cancer survivors. A
prior study examined exercise motivation over 6 months in breast cancer survivors
using the same tool, but did not also track physical activity levels (Milne et al., 2008b).
208
No other study in exercise oncology has reported using the plank exercise as a measure
of core stability. Especially among prostate cancer survivors, the plank test could be a
better choice than other exercises, such as an abdominal crunch, because of its focus on
core stability rather than rectus abdominus strength. Core stability is an integral part of
pelvic floor function and regaining continence after a prostatectomy (Dornan, 2003;
Milios, 2013; Treiyer et al., 2011).
6.6.2 Novel intervention.
Several intervention components were brought together in a novel manner to
offer participants a unique program to help them rehabilitate from cancer treatments. No
other exercise oncology studies were found that examined the implementation of
behavioural theory, group exercise and SGP in an intervention for breast and prostate
cancer survivors. This was the first exercise oncology study found to report such a
diverse, yet structured, exercise intervention. Most exercise oncology studies use one
workout program that is repeated every session (e.g. Galvao et al., 2010). The present
study used 12 unique workouts that were repeated once. The variety of the intervention
may have been the keystone for all the improvements that the participants experienced.
The participant feedback highlighted this aspect, claiming that this variety kept them
interested and motivated to attend the program.
6.7 Study Limitations
Three major limitations were identified during the research that may have
affected the outcomes of the study and the conclusions drawn from the study. The
limitations related to study design and control group behaviour, self-reporting of
physical activity, intervention compliance and the baseline characteristics of the
participants.
209
6.7.1 Study design and control group behaviour.
The greatest limitation of this study was the inability to have a fully randomised
design because the control group was recruited as a sample of convenience, mostly from
people who chose not to enrol in the intervention. Therefore, this group may not have
been representative of the typical cancer population. The analyses were probably
mitigated by the behaviour of the control participants, who had the highest mean
physical activity levels at baseline. It may be more useful for participants to be
randomised to different interventions, rather than using a true control group. Future
recommendations would be to recruit a control group who are not meeting the PAG, or
to have a wait-listed intervention.
6.7.2 Self-report of physical activity levels.
There is a tendency for people to over-report their physical activity levels on the
IPAQ (Lee et al., 2011b), and this may have contributed to the high levels of physical
activity in the sample. For this reason, outliers were removed from the analyses;
however, the variability of IPAQ scores was so great that, even after removing the
outliers, there were still very large standard deviations around the means. Such
heterogeneity in physical activity levels makes any statistical analyses difficult without
a much larger sample. However, not all of the variation in the physical activity levels
can be attributed to over-reporting. There was actually a wide variety of activity among
the participants, with some having been sedentary their whole lives and others
competing in the World Masters Games and other sporting events in the same year as
the research. However, even accepting the large variability, based on reports of typical
physical activity levels among cancer survivors (Blanchard et al., 2008; Milne et al.,
2008a; Peeters et al., 2009), one may surmise that either many of the present
210
participants significantly over-reported their physical activity levels, or that this sample
was not representative of the typical population of breast and prostate cancer survivors.
6.7.3 Intervention compliance.
The reduced differences between intended and actual aerobic exercise affected
the comparison of results between the two exercise intensity groups, especially for
VO2peak.
6.7.4 Baseline characteristics of participants.
The study population may not have been representative of typical cancer
survivors because they reported higher physical active than reported in other studies
(Blanchard et al., 2008; Milne et al., 2008a; Peeters et al., 2009). This may be a product
of the participants self-referring to the study. Baseline physical activity and exercise
motivation levels indicated that few unmotivated and sedentary cancer survivors chose
to participate in this research. Many estimates of exercise among cancer survivors
indicate that the spontaneous adoption of exercise post-diagnosis is not usual
(Blanchard et al., 2003; Demark-Wahnefried, Aziz, Rowland & Pinto, 2005;
Ottenbacher et al., 2012). This is a significant issue for exercise oncology research
because, despite knowing that the majority of cancer survivors do not achieve the PAG
(Blanchard et al., 2003), inactive survivors seem unlikely to enrol in a study that
involves an exercise intervention and physiological assessments.
Research has indicated that high stress and fatigue and low QOL are barriers to
participating in clinical trials (Biedrzycki, 2010; Bower, 2012). There have been recent
calls to identify and service the cancer survivors who are most in need of support
because they may not be accessing the available services (Bower, 2012). In contrast,
research has shown that cancer survivors who most need help will seek it out, while
those who are doing well will not (Berglund et al., 1997). Further support is needed
211
from medical oncologists to identify and refer to these services the patients who could
most benefit from exercise programs.
The demographics of the study participants were unexpectedly diverse. Some
participants had never undertaken formal exercise or visited a gym, while others had
competed in the World Masters Games during the same year that they enrolled in the
research. Another limitation to the interpretation of the data was the wide range of time
post-treatment. A common inclusion criterion in studies of post-treatment cancer
survivors is that they must be within six months of finishing acute treatments (e.g.
Battaglini et al., 2007; Rogers et al., 2011). In the current study, 40% of participants met
this criterion. The wide inclusion criteria were used for three reasons. First, by
excluding cancer survivors further out from treatment, researchers ignore the possibility
that side effects may last beyond six months, and that people may still need support for
years to come (Alibhai, Gogov & Allibhai, 2006; Binkley et al., 2012; Leonardi et al.,
2012; Weis, Poppelreuter & Bartsch, 2009). Second, many cancer survivors believe that
it is inappropriate to commit to exercise within the first year after completing treatment
(Blaney et al., 2010). Third, wider inclusion criteria increase the ability to generalise the
findings to the population.
Anecdotally, two participants in the present study, both who were six months or
fewer post-treatment, expressed regret for enrolling in the study. These people believed
they would have benefited more from the intervention if they had waited until a year or
more post-treatment, when they felt less fatigued. On the other end of the spectrum, one
woman who was two years past treatment reported that, although she knew that she
should have been exercising since her diagnosis, she did not feel mentally prepared to
enrol in an exercise program until two years after treatment. There were also some
breast and prostate cancer survivors who were a year or more post-treatment, who
212
wished they had enrolled in exercise much sooner. These varied responses, in addition
to the findings reported in the research literature, all indicate that the best time to
exercise after cancer treatment varies from person to person (Blaney et al., 2010).
People need the opportunity to learn how to exercise and to enrol in a high quality
intervention when they feel ready.
6.8 Summary
The present intervention, which combined group exercise, SGP and behaviour
modification strategies, was an effective and acceptable method of improving
physiological fitness and exercise motivation in breast and prostate cancer survivors.
However, participating in this structured intervention did not appear to have any greater
benefit for QOL. Performing the exercise at a higher intensity provided measurably
greater sustained benefits at follow up for cardiorespiratory fitness and exercise
motivation, compared to lower intensity exercise. The higher intensity exercise also
provided greater short-term improvements in strength and body composition than did
the lower intensity exercise or usual care. The sustained improvements in
cardiorespiratory fitness have positive implications for disease-free survival because
this factor is considered a strong predictor of mortality. Overall, the breast and prostate
cancer survivors responded similarly to the intervention. These results demonstrate a
measurably greater benefit of higher intensity exercise over lower intensity exercise for
some parameters.
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Chapter 7: Summary and Conclusions
Exercise proved an effective intervention for helping cancer survivors recover
from treatment side effects. However, more research is needed to optimise exercise
prescription in these populations. This research addressed three gaps in exercise
prescription for breast and prostate cancer survivors: examining exercise intensity,
comparing responses between cancer types, and promoting long-term physical activity
adoption. In an earlier study, Naumann et al. (2012a) established that combining
exercise and psychological counselling improved QOL among breast cancer survivors
more than the benefits of the individual modalities. This combination was equally
successful whether delivered individually or in a group (Naumann et al., 2012b). As this
intervention model had only been used for breast cancer survivors, the first step was to
pilot the model with a group of prostate cancer survivors. The results demonstrated that
the intervention was acceptable to the men because the exercise facilitated the SGP
component by bonding the participants and building trust. Additionally, the participants
felt a greater benefit from the combined program than they thought they would have
received from participating in either mode alone.
In the main intervention, 159 cancer survivors (n = 87 prostate cancer survivors
and n = 72 breast cancer survivors) were randomised to two exercise intensity groups
(HIG = 40, LIG = 44) or assigned to a control group (n = 75) as a separate sample of
convenience. The intervention participants were assessed on a range of physiological
and psychological parameters at baseline, post-intervention and four months postintervention to monitor the sustainability of improvements. The intervention combined
group exercise, SGP and behavioural constructs of the transtheoretical model of
behaviour change, and was delivered for eight weeks. Exercise was delivered three days
each week for 60 minutes, while SGP was delivered once per week for 90 minutes. The
214
control participants were asked to continue with their usual routines during the eightweek intervention period. They were not followed up four months post-intervention
because the follow up was interested in the sustainability of intervention gains.
The results showed that the higher intensity exercise provided greater
improvements in muscular strength and endurance and body composition than did the
lower intensity exercise or usual care. The aerobic workload of the two intensity arms
only differed by 9%, therefore eliciting similar improvements in VO2peak. The
improvements in VO2peak of both intervention groups were greater than the controls.
There were no differences between the intervention arms and control group for change
in QOL. Both intervention arms improved exercise motivation more than the control
participants. At follow up, the HIG maintained their VO2peak, body composition and
exercise motivation, while the LIG regressed on these parameters. The groups were
similar at follow up on all other physiological and psychological measures and physical
activity levels. The breast and prostate cancer survivors had similar adherence and
responses to the intervention. Based on these results, the following key findings are
presented, and recommendations for clinical practice and future research are made.
7.1 Key Findings and Conclusions
1. The multimodal intervention was suitable for both breast and prostate cancer
survivors. Despite initial concerns that the men may have rejected participating in the
SGP component, the combination with exercise facilitated its acceptability. The group
exercise promoted feelings of trust and mutual aid, and opened up communication
between the participants. Both the breast and prostate cancer survivors felt that the
group bonding in both components of the intervention was the most valuable aspect of
the program.
215
2. The higher intensity aerobic exercise was more challenging for the
participants to comply with than the lower intensity aerobic exercise. It was evident
from the monitoring of the training that the participants tended to self-select the aerobic
exercise intensity at which they preferred to train. In contrast, the participants fully
complied with the prescribed resistance training intensity because this was easier to
manipulate.
3. Those in the higher intensity exercise group showed greater short-term
physiological gains than those in the lower intensity exercise group, with the exception
of cardiorespiratory fitness. It remains to be determined whether the original target of a
15% difference in exercise intensity would be adequate to elicit a greater
cardiorespiratory training response. The exercise intensity did not modulate any of the
measured psychological responses to the intervention. Both the intervention groups
improved exercise motivation to a similar extent. The group exercise and SGP
intervention did not provide any additional benefit to QOL or fatigue, compared to the
usual care. This was possibly a reflection of the fact that the control group was highly
active and perhaps eliciting their own benefits outside the structured intervention.
4. The participants who exercised at the higher intensity were better able to
maintain their cardiorespiratory fitness and exercise motivation than were the lower
intensity exercise group. All the intervention participants maintained or slightly
regressed on measures of strength, QOL and fatigue.
5. Both the breast and prostate cancer survivors adapted similarly to the
intervention, thus indicating that this multimodal program was efficacious for both
populations.
6. The exercise intensity did not affect the physical activity levels at follow up.
The participants maintained a high level of physical activity throughout the
216
sustainability period, although the prostate cancer survivors engaged in more physical
activity than did the breast cancer survivors. Consideration needs to be given to what
cancer survivors do beyond a structured exercise intervention because the benefits from
training can only be maintained if the exercise regime is continued in the long term.
7.2 Recommendations for Clinical Practice
The following recommendations for clinical and research practice are based on
the results of the present study.
1. Clinical interventions should adopt this multimodal approach to providing
physiological and psychological support services to breast and prostate cancer survivors
for a more comprehensive program for both men and women in rehabilitation.
2. For maximal physiological benefit, aerobic and resistance exercise should be
performed simultaneously. The results of the present study indicate that 70% VO2peak
and 65 to 80%1RM are suitable starting points for higher intensity exercise.
3. Exercise interventions should include a wide range of activities. The exercise
intervention employed in this study included a variety of exercises to maximise
participant interest, motivation and enjoyment of the exercise sessions. Longer
interventions should continue to add variety to keep participants entertained and
motivated to participate. Additional modes of exercise that were employed in this
intervention, such as yoga or Pilates, could be incorporated.
4. While social support was discussed extensively as part of the behaviour
modification strategies during the intervention, no attempt was made to pair participants
together after the intervention. Exercise physiologists should considering formalising
this process by encouraging participants to form pairs or small groups in order to
encourage each other’s continued physical activity.
217
5. Strategies need to be devised to encourage cancer survivors to improve their
autonomous motivation to exercise. Using the TTM and monitoring exercise motivation
with the BREQ-2 could be useful in transferring the onus of exercising from being
intervention-led to a self-sustaining model. It may be possible to identify those
participants who lack the necessary levels of exercise motivation and then provide
additional support to them.
6. Group exercise can facilitate men’s participation in group mental health
services, and should be considered a useful supportive tool to draw men into supportive
mental health services. Many men indicated that they received enormous benefits from
the SGP, but may not have sought it out if it was offered separately from the exercise
program.
7.3 Recommendations for Future Research
The following recommendations are made for future research.
1. It would be valuable to repeat the same intervention used to compare
intensities, but enrol only participants with a low baseline level of physical activity.
2. The SGP component of the intervention could be removed to examine the
effects of exercise intensity alone on psychological outcomes.
3. There is still a need to determine the dose–response relationships between
exercise intensity and QOL and fitness outcomes. Future studies should ensure a
minimum 15% difference between intensity levels is implemented to determine if
exercise intensity influences training outcomes for cancer survivors. Higher intensity
aerobic exercise may be best achieved through high intensity interval training.
4. Exercise intensity could also be examined in combination with other
prescription variables, such as frequency and duration. For example, the present design
218
of three days per week for 60 minutes could be compared against five days per week for
30 minutes or seven days per week for 15 minutes.
5. Better strategies to increase aerobic exercise compliance are also needed.
Some possible solutions could be using speed or power generation to monitor the
workload. Additionally, prescribing modes of exercise that are more naturally suited to
achieving higher intensities, such as walking up hills or stairs, could be useful. Another
option would be to not measure intensity objectively. The clearest example of this can
be seen by considering performing sprint intervals on a stationary bicycle. High
intensity interval training may be more feasible and allow for better compliance than
continuous high intensity aerobic exercise. People can be instructed to pedal as hard as
they can for a small interval, and then have a less intense active recovery period in the
other part of the interval. To help quantify doses for research purposes, a first step
would be to confirm the validity and reproducibility of using this subjective technique—
perhaps by measuring average or total watts generated on a bike during high intensity
intervals or using session RPE.
6. More investigations are needed into incontinence and sexual dysfunction in
prostate cancer survivors, both as physical symptoms and in terms of their contribution
to perceptions of QOL. Specifically, research should examine how a general exercise
routine affects these needs. Additionally, the plank test—used in the present study to
assess core stability—could be investigated for its association with pelvic floor activity
and incontinence. Pelvic floor function should be measured via ultrasound, following
the methods of Milios (2013).
7. The outcomes of this study show that using a higher intensity and
proportionally lower volume provided measurable physiological benefits to cancer
survivors. Considering that time commitments are major barriers to engaging in
219
exercise, cancer survivors may be more likely to engage in an evidence-based exercise
program of minimal volume, but higher intensity. Future research could determine the
absolute minimum volume of exercise needed, if performed at a sufficiently high
intensity. Based on a mixture of results, ranging from clinical populations to elite
athletes, there is some merit to the idea that only two or three 10-minute interval
sessions of aerobic exercise per week could provide significant benefit.
8. Researchers should reflect on the need and utility of attempting to have a true
control group, considering that the control participants in this study independently
increased their exercise. Additionally, there are ethical implications related to denying
cancer survivors access to effective exercise interventions, given there is so much
evidence to support its benefits. Perhaps instead of comparing single interventions
against a control group, future research should simply use wait-list control groups, in
which participants act as controls for a period before being enrolled in the intervention.
7.4 Closing Remarks
The results of the present study create a new set of possibilities, related to higher
intensity exercise and program design, to be incorporated and optimised in future
research and practice. Higher intensity exercise has the potential to provide greater
short- and long-term benefits to breast and prostate cancer survivors, as opposed to
lower intensity exercise of a more sustained duration. However, lower intensity exercise
is still preferable to no exercise at all. The field of exercise oncology is still relatively in
its infancy, with further research needed in terms of both the basic science and clinical
practice. The results of this project have demonstrated that exercise at a higher intensity
than usually prescribed has the potential to provide some additional and more
sustainable physiological and motivational benefits for both breast and prostate cancer
survivors.
220
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278
Appendix A. Information Sheets and Informed Consent Forms
279
Effects of a Combined Group Exercise and Counselling Program on
Selected Physiological and Psychological Parameters in Breast
Cancer Survivors.
I N F O R M AT I O N S H E E T
Aims of the Project
Breast cancer is the most common cancer experienced by Australian women, with
survival rates rising. People who survive cancer know that they must develop the
inner strength to cope with the physiological and psychological issues that arise as a
result of cancer treatment. Thus, the aim of this project is to provide valuable
information on the benefits of a combined group exercise and counselling program
on the health and well-being of breast cancer survivors through participation in a
structured rehabilitation program.
Information About How the Project Runs
This study, which is partly funded by HBF insurance, offers a 10 week, combined
group exercise and counselling program. All sessions occur at the University of
Notre Dame Australia in Fremantle. The schedule is outlined below.
Week 1: Your first “week” will occur before the program start date, and will include 2
appointments for assessments and one appointment to meet with the counsellor. On
the first assessment day we will measure your resting heart rate, blood pressure,
height, weight, skinfolds and girth measurements. You will then be asked to
participate in flexibility tests, and lastly a cardiovascular endurance test (VO 2 peak
test). This test requires you to use a stationary cycle while wearing a mouthpiece to
collect gas exchange. On the second assessment day you will repeat the
cardiovascular endurance test before performing strength tests. In between testing
days you will be asked to fill out questionnaires pertinent to our research. You will
complete your two days of assessments by yourself. Eric will book in your
assessments, and the counsellor will call you to book in your meeting with them.
Weeks 2-9: You will attend the Exercise Rehabilitation Laboratory at the University
of Notre Dame on Monday, Wednesday, and Friday for an hour of exercise each day
as a group. Activities you will perform include weight lifting, aerobic exercise
(treadmill, stationary bicycle, rowing machine), stretching, and hydrotherapy pool
sessions. All exercise sessions will be led and supervised by an Accredited Exercise
Physiologist, licensed through Exercise and Sport Science of Australia. Also, on one
of those days (the exact day depends upon the course you enrol in) you will have a
90 minute group counselling session. The counselling will be held at the School of
Counselling (a 5 minute walk from the exercise building) and facilitated by two
trained counsellors. During this time, we will also ask you to fill in a log of any
exercise you perform outside of the program.
Week 10: The final assessment will be done all in one day, and will last a full hour.
You will repeat all the tests, but will only do the bike test once. You may be asked to
also participate in a 20-30 minute exit interview with an independent researcher.
280
You will also be asked to participate in a follow up assessment 4 months after
completing the program. This assessment will only be the physical tests, and not any
of the other interviews, and will be completed in one day, like it was in week 10.
In general, the program asks you to commit to coming to the university 3 days per
week, for a total of 4.5 hours in the week. Of course, doctor appointments and other
commitments always keep people from being able to attend 100% of the sessions,
and we understand that there will be conflicts. However, we ask that you try to
schedule things around the program times. There will be NO penalty for missing a
session.
This study is voluntary and you are under no obligation to take part in the study. You
will not incur any costs for participating in this project, except parking if you drive and
park in a metered spot. You may withdraw from the study at any time with no
hindrance of access to appropriate care. If you do withdraw, we will ask you for the
reason for withdrawal, as this information factors into our research.
Data will be stored securely in the School of Health Sciences at The University of
Notre Dame Australia for five years.
All testing and training sessions will be performed on campus at the University of
Notre Dame Australia, Fremantle Campus, at the Institute for Health and
Rehabilitation Research. Testing and training sessions will be supervised by the lead
researcher, Eric Martin. All counselling sessions will be performed on campus at the
School of Counselling.
Potential Risks
There should be no psychological or physiological harm caused by the study. Some
risks are associated with exercising, but appropriate supervision and teaching from
the trainers will minimize this risk. Screening tools will be implemented prior to
participating in the testing or exercise program, which should minimise potential risks
associated with exercising. All exercise sessions will be administered by exercise
physiologists and monitored by an Accredited Exercise Physiologist who specializes
in working with cancer survivors. The counselling sessions will be facilitated by a
qualified counsellor.
All information will be protected and only individuals on the research team will have
access to the information. Names will be erased from individual data collection
sheets and replaced with an identification number to correlate an individual’s sets of
data. Data will be discarded if a participant chooses to withdraw.
Proposed Benefits
There are no promised benefits to any person participating in the study, besides the
known possible improvements in overall health and fitness. There is growing
empirical evidence to suggest that exercise can be beneficial to cancer patients,
which includes but is not limited to: reduced fatigue levels; increased physical
function; improved cardiovascular fitness and strength; and maintained or improved
quality of life.
281
This study seeks to increase the body of knowledge of benefits that exercise and
counselling have for post-treated breast cancer patients. Some parts of this study
are being undertaken as part of the course to fulfil the requirements of a Doctor of
Philosophy candidate, Eric Martin. If this intervention proves successful, it could
have applications for breast cancer survivors throughout Australia.
Should you have any further questions about the project or have any concerns about
the manner in which the project is being conducted, please feel free to contact the
principal researchers:
Eric Martin, MA
Program Manager
The University of Notre Dame Australia
Telephone: (08) 9433 0906
Mobile: 04 2407 6995
Email: [email protected]
We look forward to talking to you soon.
Eric Martin
If participants have any complaint regarding the manner in which a research project is conducted, it
should be directed to the Executive Officer of the Human Research Ethics Committee, Research
Office, The University of Notre Dame Australia, PO Box 1225 Fremantle WA 6959, phone (08) 9433
0943.
282
Effects of a Combined Group Exercise and Counselling Program on
Selected Physiological and Psychological Parameters in Prostate
Cancer Survivors.
I N F O R M AT I O N S H E E T
Aims of the Project
Prostate cancer is the most common cancer experienced by Australian men, with
survival rates rising. People who survive cancer know that they must develop the
inner strength to cope with the physiological and psychological issues that arise as a
result of cancer treatment. Thus, the aim of this project is to provide valuable
information on the benefits of a combined group exercise and counselling program
on the health and well-being of prostate cancer survivors through participation in a
structured rehabilitation program.
Information About How the Project Runs
This study, which is partly funded by HBF insurance, offers a 10 week, combined
group exercise and counselling program. All sessions occur at the University of
Notre Dame Australia in Fremantle. The schedule is outlined below.
Week 1: Your first “week” will occur before the program start date, and will include 2
appointments for assessments and one appointment to meet with the counsellor. On
the first assessment day we will measure your resting heart rate, blood pressure,
height, weight, skinfolds and girth measurements. You will then be asked to
participate in flexibility tests, and lastly a cardiovascular endurance test (VO 2 peak
test). This test requires you to use a stationary cycle while wearing a mouthpiece to
collect gas exchange. On the second assessment day you will repeat the
cardiovascular endurance test before performing strength tests. In between testing
days you will be asked to fill out questionnaires pertinent to our research. You will
complete your two days of assessments by yourself. Eric will book in your
assessments, and the counsellor will call you to book in your meeting with them.
Weeks 2-9: You will attend the Exercise Rehabilitation Laboratory at the University
of Notre Dame on Monday, Wednesday, and Friday for an hour of exercise each day
as a group. Activities you will perform include weight lifting, aerobic exercise
(treadmill, stationary bicycle, rowing machine), stretching, and hydrotherapy pool
sessions. All exercise sessions will be led and supervised by an Accredited Exercise
Physiologist, licensed through Exercise and Sport Science of Australia. Also, on one
of those days (the exact day depends upon the course you enrol in) you will have a
90 minute group counselling session. The counselling will be held at the School of
Counselling (a 5 minute walk from the exercise building) and facilitated by two
trained counsellors. During this time, we will also ask you to fill in a log of any
exercise you perform outside of the program
Week 10: The final assessment will be done all in one day, and will last a full hour.
You will repeat all the tests, but will only do the bike test once. You may be asked to
also participate in a 20-30 minute exit interview with an independent researcher.
283
You will also be asked to participate in a follow up assessment 4 months after
completing the program. This assessment will only be the physical tests, and not any
of the other interviews, and will be completed in one day, like it was in week 10.
In general, the program asks you to commit to coming to the university 3 days per
week, for a total of 4.5 hours in the week. Of course, doctor appointments and other
commitments always keep people from being able to attend 100% of the sessions,
and we understand that there will be conflicts. However, we ask that you try to
schedule things around the program times. There will be NO penalty for missing a
session.
This study is voluntary and you are under no obligation to take part in the study. You
will not incur any costs for participating in this project, except parking if you drive and
park in a metered spot. You may withdraw from the study at any time with no
hindrance of access to appropriate care. If you do withdraw, we will ask you for the
reason for withdrawal, as this information factors into our research.
Data will be stored securely in the School of Health Sciences at The University of
Notre Dame Australia for five years.
All testing and training sessions will be performed on campus at the University of
Notre Dame Australia, Fremantle Campus, at the Institute for Health and
Rehabilitation Research. Testing and training sessions will be supervised by the lead
researcher, Eric Martin. All counselling sessions will be performed on campus at the
School of Counselling.
Potential Risks
There should be no psychological or physiological harm caused by the study. Some
risks are associated with exercising, but appropriate supervision and teaching from
the trainers will minimize this risk. Screening tools will be implemented prior to
participating in the testing or exercise program, which should minimise potential risks
associated with exercising. All exercise sessions will be administered by exercise
physiologists and monitored by an Accredited Exercise Physiologist who specializes
in working with cancer survivors. The counselling sessions will be facilitated by a
qualified counsellor.
All information will be protected and only individuals on the research team will have
access to the information. Names will be erased from individual data collection
sheets and replaced with an identification number to correlate an individual’s sets of
data. Data will be discarded if a participant chooses to withdraw.
Proposed Benefits
There are no promised benefits to any person participating in the study, besides the
known possible improvements in overall health and fitness. There is growing
empirical evidence to suggest that exercise can be beneficial to cancer patients,
which includes but is not limited to: reduced fatigue levels; increased physical
function; improved cardiovascular fitness and strength; and maintained or improved
quality of life.
284
This study seeks to increase the body of knowledge of benefits that exercise and
counselling have for post-treated prostate cancer patients. Some parts of this study
are being undertaken as part of the course to fulfil the requirements of a Doctor of
Philosophy candidate, Eric Martin. If this intervention proves effective, it could have
applications for all cancer survivors throughout Australia.
Should you have any further questions about the project or have any concerns about
the manner in which the project is being conducted, please feel free to contact the
principal researchers:
Eric Martin, MA
Program Manager
The University of Notre Dame Australia
Telephone: (08) 9433 0906
Mobile: 04 2407 6995
Email: [email protected]
We look forward to talking to you soon.
Eric Martin
0943.
285
Effects of a Combined Group Exercise and Counselling Program
on Selected Physiological and Psychological Parameters in
Prostate Cancer Survivors.
INFORMED CONSENT FORM
I, (participant’s name) _________________________________hereby agree to
being a participant in the above research project.
 I have read and understood the Information Sheet about this project and any
questions have been answered to my satisfaction.
 I understand that I may withdraw from participating in the project at any time
without prejudice.
 I understand that all information gathered by the researcher will be treated as
strictly confidential.
 I agree that any research data gathered for the study may be published
provided my name or other identifying information is not disclosed.

I understand that the final focus group interview will be audio recorded.
PARTICIPANT’S
SIGNATURE:
RESEARCHER’S FULL
NAME:
DATE:
ERIC MARTIN
RESEARCHER’S
SIGNATURE:
DATE:
0943.
286
Effects of a Combined Group Exercise and Counselling Program
on Selected Physiological and Psychological Parameters in
Breast Cancer Survivors.
INFORMED CONSENT FORM
I, (participant’s name) _________________________________hereby agree to
being a participant in the above research project.
 I have read and understood the Information Sheet about this project and any
questions have been answered to my satisfaction.
 I understand that I may withdraw from participating in the project at any time
without prejudice.
 I understand that all information gathered by the researcher will be treated as
strictly confidential.
 I agree that any research data gathered for the study may be published
provided my name or other identifying information is not disclosed.

I understand that the final focus group interview will be audio recorded.
PARTICIPANT’S
SIGNATURE:
RESEARCHER’S FULL
NAME:
DATE:
ERIC MARTIN
RESEARCHER’S
SIGNATURE:
DATE:
0943.
287
Appendix B. Demographics Questionnaire
288
Cancer Survivorship Program
Demographics Questionnaire
The purpose of this questionnaire is to gather demographic and health-services-use
information about participants in the Cancer Survivorship Program. The information gathered
through this research will identify key health-care support factors contributing to successful
recovery and survivorship.
Please do NOT put your name anywhere on the documents. This questionnaire will remain
entirely anonymous, and will only be used by the authorized research team members. If you
do not wish to answer a particular question, please leave it blank.
Thank you, in advance, for filling out this questionnaire.
Sex
□ Male
Date of Birth: ___________
□
Female
Post Code: _____________
Country of Birth:_____________________
Marital status
□ Single
□ Married/De Facto
□ Divorced
□ Widowed
Education
Please check the box that describes the highest level of education you have achieved.
□ Completed year 10
□ Completed a post-graduate
□ Completed year 12
qualification/degree
□ Completed TAFE or other
□ Other: __________________
vocational qualification
□ Completed an undergraduate
degree
How many hours do you currently work per week in paid employment?
Please tick the box that best answers the question.
□ Not currently working
□ Working 20-39 hours
□ Working 1-19 hours
□ Working 40+ hours
Are You Retired?
□ Yes
□ No
Income
Please check the box that describes your household’s yearly income.
□ $0-$6,000
□ $80,001-$180,000
□ $6,001-$35,000
□ Over $180,000
□ $35,001-$80,000
Do You Have Private Health Insurance?
□ Yes
□ No
289
Appendix C. Copies of Standardized Questionnaires
290
291
292
293
294
295
296
EXERCISE REGULATIONS QUESTIONNAIRE (BREQ-2)
Age:
___________ years
Sex: male female (please circle)
WHY DO YOU ENGAGE IN EXERCISE?
We are interested in the reasons underlying peoples’ decisions to engage, or
not engage in physical exercise. Using the scale below, please indicate to
what extent each of the following items is true for you. Please note that
there are no right or wrong answers and no trick questions. We simply
want to know how you personally feel about exercise. Your responses will
be held in confidence and only used for our research purposes.
Not true
for me
Sometimes
true for me
Very true
for me
1
I exercise because other people
say I should
0
1
2
3
4
2
I feel guilty when I don’t exercise
0
1
2
3
4
3
I value the benefits of exercise
0
1
2
3
4
4
I exercise because it’s fun
0
1
2
3
4
5
I don’t see why I should have to exercise
0
1
2
3
4
6
I take part in exercise because my
friends/family/partner say I should
0
1
2
3
4
7
I feel ashamed when I miss an
exercise session
0
1
2
3
4
8
It’s important to me to exercise regularly
0
1
2
3
4
9
I can’t see why I should bother exercising
0
1
2
3
4
297
Not true
for me
Sometimes
true for me
Very true
for me
10 I enjoy my exercise sessions
0
1
2
3
4
11 I exercise because others will not be
pleased with me if I don’t
0
1
2
3
4
12 I don’t see the point in exercising
0
1
2
3
4
13 I feel like a failure when I haven’t
exercised in a while
0
1
2
3
4
14 I think it is important to make the effort to
exercise regularly
0
1
2
3
4
15 I find exercise a pleasurable activity
0
1
2
3
4
16 I feel under pressure from my friends/family 0
to exercise
1
2
3
4
17 I get restless if I don’t exercise regularly
0
1
2
3
4
18 I get pleasure and satisfaction from
participating in exercise
0
1
2
3
4
19 I think exercising is a waste of time
0
1
2
3
4
298
299
300
Tense
301
302
INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE
We are interested in finding out about the kinds of physical activities that people do
as part of their everyday lives. The questions will ask you about the time you spent
being physically active in the last 7 days. Please answer each question even if you
do not consider yourself to be an active person. Please think about the activities you
do at work, as part of your house and yard work, to get from place to place, and in
your spare time for recreation, exercise or sport.
Think about all the vigorous activities that you did in the last 7 days. Vigorous
physical activities refer to activities that take hard physical effort and make you
breathe much harder than normal. Think only about those physical activities that you
did for at least 10 minutes at a time.
1.
During the last 7 days, on how many days did you do vigorous physical
activities like heavy lifting, digging, aerobics, or fast bicycling?
_____ days per week
No vigorous physical activities
2.
Skip to question 3
How much time did you usually spend doing vigorous physical activities on one of
those days?
_____ hours per day OR
_____ minutes per day
Don’t know/Not sure
Think about all the moderate activities that you did in the last 7 days. Moderate
activities refer to activities that take moderate physical effort and make you breathe
somewhat harder than normal. Think only about those physical activities that you
did for at least 10 minutes at a time.
3.
During the last 7 days, on how many days did you do moderate physical
activities like carrying light loads, bicycling at a regular pace, or doubles
tennis? Do not include walking.
_____ days per week
No moderate physical activities
303
Skip to question 5
4.
How much time did you usually spend doing moderate physical activities on one of
those days?
Think about the time you spent walking in the last 7 days. This includes at work
and at home, walking to travel from place to place, and any other walking that you
might do solely for recreation, sport, exercise, or leisure.
5.
During the last 7 days, on how many days did you walk for at least 10
minutes at a time?
_____ days per week
No walking
6.
How much time did you usually spend walking on one of those days?
304
Appendix D. Semi Structured Interview Questions for Narrative
Feedback
305
1. Please describe your overall experience of the program.
2. How would you describe your experience in the counselling sessions?
3. How would you describe your experience in the exercise sessions?
4. How did you feel the two componenets, exercise and counselling, interacted to
influence your overall experience?
5. Do you have any recommendations for how this program could be improved?
306
Appendix E. Raw Group Means at all Assessments, Divided by
Cancer Types
307
Table E1
Raw Outcomes (M, SD) for Prostate Cancer Survivors
Assessment and Measure
Baseline weight (kg)
Post intervention weight (kg)
Follow up weight (kg)
Baseline BF%
Post intervention BF%
Follow up BF%
Baseline sit and reach (cm from toes)
Post intervention sit and reach (cm from
toes)
Follow up sit and reach (cm from toes)
Baseline shoulder ROM (degrees)
Post intervention shoulder ROM
(degrees)
Follow up shoulder ROM (degrees)
Baseline VO2peak (mL/kg/min)
Post intervention VO2peak (mL/kg/min)
Follow up VO2peak (mL/kg/min)
Baseline push ups (repetitions)
Post intervention push ups (repetitions)
Follow up push ups (repetitions)
Baseline plank (seconds)
Post intervention plank (seconds)
Follow up plank (seconds)
Baseline leg press 1RM (kg)
Post intervention leg press 1RM (kg)
Follow up leg press 1RM (kg)
Baseline FACT-G
Post intervention FACT-G
Follow up FACT-G
Baseline PWB
Post intervention PWB
Follow up PWB
Baseline SWB
Post intervention SWB
Follow up SWB
LIG
HIG
C
M
81.8
81.8
81.0
21.8
20.7
20.8
-8.7
SD
9.0
9.7
7.7
4.8
4.7
3.7
10.9
M
83.8
84.2
83.6
22.8
21.0
21.0
-7.3
SD
11.7
11.9
10.3
5.1
4.8
4.2
7.0
-4.2
9.1
-5.2
-5.4
724.8
10.0
55.2
747.5
739.9
25.4
27.8
27.4
6.9
11.4
13.9
94.0
113.4
116.8
105.6
111.8
114.5
82.5
85.7
84.7
22.6
24.1
23.8
21.3
20.3
21.2
308
M
84.2
82.5
SD
12.3
12.4
22.8
22.1
4.8
6.2
-11.5
10.8
8.1
-9.7
9.2
-5.5
730.9
7.7
51.3
729.6
70.6
45.5
746.0
51.5
734.6
43.8
54.9
5.4
5.6
6.7
7.7
9.5
11.8
59.7
63.5
65.1
34.2
26.0
52.8
16.4
14.5
12.3
4.1
3.6
3.4
4.6
4.7
4.0
743.5
23.2
25.2
25.1
6.2
11.1
11.1
66.4
95.7
86.4
111.9
126.9
125.7
84.2
86.0
87.9
22.9
23.9
23.3
20.2
20.2
21.5
50.5
4.5
4.5
5.2
7.1
9.8
9.9
35.3
43.1
30.5
32.6
32.6
32.8
11.8
12.0
9.7
3.6
3.9
3.4
3.9
3.6
3.5
26.2
26.2
6.5
6.1
8.4
8.5
10.2
10.7
76.5
94.0
50.5
62.9
123.1
120.0
35.4
35.4
87.3
90.1
12.7
9.6
23.7
24.0
4.2
3.3
20.9
21.5
5.0
4.4
Table E1 (continued)
Baseline EWB
Post intervention EWB
Follow up EWB
Baseline FWB
Post intervention FWB
Follow up FWB
Baseline Additional Concerns
Post intervention Additional Concerns
Follow up Additional Concerns
Baseline FACT-P
Post intervention FACT-P
Follow up FACT-P
Baseline RAI (overall exercise
motivation)
Post intervention RAI (overall exercise
motivation)
Follow up RAI (overall exercise
motivation)
Baseline amotivation
Post intervention amotivation
Follow up amotivation
Baseline external regulation
Post intervention external regulation
Follow up external regulation
Baseline introjected regulation
Post intervention introjected regulation
Follow up introjected regulation
Baseline identified regulation
Post intervention identified regulation
Follow up identified regulation
Baseline intrinsic regulation
Post intervention intrinsic regulation
Follow up intrinsic regulation
LIG
HIG
C
M
19.2
20.3
19.2
19.4
21.0
20.5
31.3
35.8
34.4
113.9
121.5
119.1
SD
4.7
3.7
4.0
6.5
5.2
5.0
8.0
6.1
7.1
22.4
18.8
18.0
M
19.8
20.0
20.7
21.3
21.9
22.4
33.1
34.5
33.1
117.2
120.5
121.0
SD
2.9
3.5
2.4
4.2
4.3
3.6
5.3
5.8
5.1
15.4
17.1
12.4
8.6
6.9
11.0
11.4
5.9
8.4
.4
.2
.4
.4
.5
.7
1.2
1.9
1.8
2.7
3.1
2.8
2.1
2.9
2.4
309
M
20.0
20.3
SD
3.8
2.8
22.7
24.2
5.4
3.1
34.9
35.9
6.2
6.7
122.2
126.0
17.4
14.9
6.1
9.4
7.2
12.1
5.9
11.3
5.4
7.3
12.9
4.6
.6
.6
.8
.7
.8
.9
.9
1.1
1.0
.9
.9
.9
1.2
.9
1.2
.2
.3
.1
.6
.5
.4
1.2
1.6
1.6
2.9
3.2
3.2
2.8
3.1
3.1
.6
.6
.3
.9
.8
.7
1.1
1.1
1.2
.8
.7
.7
.8
.9
.9
.4
.1
.7
.2
.8
.7
.9
1.0
1.4
1.4
1.2
1.1
3.0
3.0
.8
.8
2.6
2.7
1.1
1.0
Baseline overall fatigue (PFS)
Post intervention overall fatigue (PFS)
Follow up overall fatigue (PFS)
Baseline behavioral fatigue
Post intervention behavioral fatigue
Follow up behavioral fatigue
Baseline affective fatigue
Post intervention affective fatigue
Follow up affective fatigue
Baseline sensory fatigue
Post intervention sensory fatigue
Follow up sensory fatigue
Baseline cognitive fatigue
Post intervention cognitive fatigue
Follow up cognitive fatigue
LIG
M
SD
3.9 2.2
2.8 1.8
3.2 2.4
2.8 2.7
1.4 1.9
1.9 2.7
3.6 3.1
2.3 3.0
2.5 3.4
4.8 2.3
3.7 1.9
4.2 2.1
4.5 1.9
3.7 1.6
4.2 2.1
310
HIG
M
SD
3.5 2.2
3.3 1.8
3.2 2.1
2.2 2.2
1.9 2.0
1.9 2.5
3.5 3.2
3.2 3.2
2.7 3.2
4.4 2.2
4.2 1.8
4.3 1.6
4.0 1.8
3.8 1.6
3.9 1.8
C
M
2.8
2.6
SD
1.9
1.5
1.7
1.5
2.1
1.7
2.5
2.2
2.8
2.5
3.5
3.3
1.9
1.9
3.5
3.2
1.7
1.7
Table E2
Raw Outcomes (M, SD) for Breast Cancer Survivors
Baseline weight (kg)
Post intervention weight (kg)
Follow up weight (kg)
Baseline BF%
Post intervention BF%
Follow up BF%
Baseline sit and reach (cm from toes)
Post intervention sit and reach (cm from
toes)
Follow up sit and reach (cm from toes)
Baseline shoulder ROM (degrees)
Post intervention shoulder ROM
(degrees)
Follow up shoulder ROM (degrees)
Baseline VO2peak (mL/kg/min)
Post intervention VO2peak (mL/kg/min)
Follow up VO2peak (mL/kg/min)
Baseline push ups (repetitions)
Post intervention push ups (repetitions)
Follow up push ups (repetitions)
Baseline plank (seconds)
Post intervention plank (seconds)
Follow up plank (seconds)
Baseline leg press 1RM (kg)
Post intervention leg press 1RM (kg)
Follow up leg press 1RM (kg)
Baseline FACT-G
Post intervention FACT-G
Follow up FACT-G
Baseline PWB
Post intervention PWB
Follow up PWB
Baseline SWB
Post intervention SWB
Follow up SWB
Baseline EWB
Post intervention EWB
Follow up EWB
LIG
HIG
C
M
70.1
70.0
70.9
31.0
30.0
29.7
1.8
SD
14.0
15.1
14.7
8.5
8.4
9.4
8.0
M
74.9
72.2
72.9
31.8
28.6
27.0
6.3
SD
14.2
12.3
13.0
5.5
4.5
5.8
9.1
M
70.7
71.9
SD
15.0
15.5
29.2
29.8
7.0
7.2
.1
9.9
4.5
7.3
7.3
8.2
3.7
10.4
3.9
705.1
7.0
67.8
7.1
760.8
8.5
32.2
733.8
60.8
747.7
39.9
771.7
33.0
751.9
34.1
734.5
21.2
22.7
20.9
7.8
10.4
10.9
50.4
77.2
62.4
85.3
108.2
101.5
81.8
84.0
82.0
21.1
22.3
20.4
20.7
20.8
21.5
19.2
19.6
19.3
48.2
5.0
5.3
5.5
10.4
11.0
17.1
56.3
70.3
65.1
28.0
47.1
37.6
15.5
16.8
18.8
4.4
4.5
6.2
5.7
6.0
5.4
3.8
4.0
4.3
770.7
22.2
24.7
25.2
8.5
17.3
15.9
52.1
71.7
55.1
104.2
132.5
148.9
83.8
90.9
85.3
21.7
24.3
22.8
23.5
24.0
21.8
17.9
19.6
20.3
23.7
5.9
5.6
7.1
9.1
13.0
15.3
41.1
47.5
40.3
43.4
54.0
80.3
13.2
9.3
13.9
5.6
3.0
4.3
3.1
3.5
5.3
3.6
2.6
2.4
21.3
22.4
6.7
6.8
7.0
11.0
9.3
12.1
58.6
61.0
57.5
60.5
89.3
109.5
28.7
35.0
83.8
91.1
13.5
11.6
22.5
24.7
4.2
2.8
20.7
22.1
5.8
5.4
19.7
20.6
3.7
3.2
311
Baseline FWB
Post intervention FWB
Follow up FWB
Baseline Additional Concerns
Post intervention Additional Concerns
Follow up Additional Concerns
Baseline FACT-B
Post intervention FACT-B
Follow up FACT-B
Baseline RAI (overall exercise
motivation)
Post intervention RAI (overall exercise
motivation)
Follow up RAI (overall exercise
motivation)
Baseline amotivation
Post intervention amotivation
Follow up amotivation
Baseline external regulation
Post intervention external regulation
Follow up external regulation
Baseline introjected regulation
Post intervention introjected regulation
Follow up introjected regulation
Baseline identified regulation
Post intervention identified regulation
Follow up identified regulation
Baseline intrinsic regulation
Post intervention intrinsic regulation
Follow up intrinsic regulation
Baseline overall fatigue (PFS)
Post intervention overall fatigue (PFS)
Follow up overall fatigue (PFS)
Baseline behavioral fatigue
Post intervention behavioral fatigue
Follow up behavioral fatigue
Baseline affective fatigue
Post intervention affective fatigue
Follow up affective fatigue
LIG
HIG
C
M
20.8
21.4
20.8
22.3
23.0
23.3
104.1
107.0
105.3
SD
5.0
4.8
5.6
6.1
6.5
6.2
19.2
21.0
23.3
M
20.7
23.0
20.5
23.0
26.0
26.7
106.8
116.9
111.9
SD
4.4
3.2
4.0
5.9
5.5
5.1
17.2
12.8
16.9
13.3
5.3
9.2
14.4
3.9
12.2
.0
.0
.2
.2
.3
.4
1.4
1.5
1.5
3.2
3.6
3.3
2.9
3.1
2.8
4.7
3.5
3.7
4.0
2.8
2.8
5.0
3.3
3.0
312
M
20.9
23.8
SD
4.4
3.7
23.9
25.1
6.5
7.0
107.6
116.2
18.5
16.9
6.1
9.8
7.1
10.7
5.2
11.0
6.3
5.8
11.5
6.3
.1
.2
.4
.3
.4
.8
.8
1.0
1.2
.8
.6
.8
1.1
.8
1.0
2.1
2.2
2.6
2.8
2.6
3.4
2.8
3.1
3.5
.1
.1
.0
.8
.8
.6
1.5
1.9
1.9
2.8
3.2
3.2
2.4
2.8
2.8
3.9
3.3
3.9
2.9
1.8
2.6
3.9
2.8
4.2
.4
.3
.1
1.1
1.2
.9
1.1
1.3
1.0
.7
.5
.7
1.2
.9
1.3
2.1
1.7
2.4
2.6
2.0
2.6
3.2
3.1
3.5
.3
.2
.7
.3
.5
.3
.6
.6
1.4
1.6
.9
.9
2.8
2.9
1.0
1.0
2.4
2.6
1.3
1.1
3.6
2.7
2.1
1.9
2.6
1.6
2.8
2.2
3.5
2.0
3.0
2.7
Baseline sensory fatigue
Post intervention sensory fatigue
Follow up sensory fatigue
Baseline cognitive fatigue
Post intervention cognitive fatigue
Follow up cognitive fatigue
LIG
M
SD
5.1
2.2
4.1
2.3
4.4
2.4
4.6
1.8
3.8
1.8
4.5
1.8
313
HIG
M
4.4
4.4
4.7
4.5
4.3
4.3
C
SD
1.9
1.6
2.4
1.6
1.4
1.8
M
4.4
3.6
SD
2.1
2.2
4.0
3.6
1.8
1.9
Appendix F. Example Training Log
314
Week 1 Monday
Volume
Person 1
Rx done
Person 2
Rx done
Person 3
Rx done
Person 4
Rx done
walk outside
315
25 min
stretch quads, hamstrings, chest, shoulders, triceps, wall crawls for 20 seconds
Wall pushups
8
BW
BW
BW
BW
Standing reverse fly
12
BW
BW
BW
BW
Chair squats
12
BW
BW
BW
BW
Standing side bends
10
BW
BW
BW
BW
Seated knee crunches
8
BW
BW
BW
BW
Bench dips
5
BW
BW
BW
BW
Standing hip abduction
10
BW
BW
BW
BW
Calf raises
15
BW
BW
BW
BW
stretch quads, hamstrings, chest, shoulders, triceps, wall crawls for 20 seconds
Session rating of perceived
exertion
Notes
Person 5
Rx done
BW
BW
BW
BW
BW
BW
BW
BW
Appendix G. Exercise Sessions
316
Week 1 and 5 Monday
317
Walk outside
stretch quads, hamstrings, chest, shoulders, triceps, 5 wall crawls
Wall push ups
Standing reverse fly
Shair squats
Standing side bends
Seated knee crunches
Bench dips
Standing hip abduction
Calf raises
stretch quads, hamstrings, chest, shoulders, triceps, 5 wall crawls
Volume
25 min for LIG, 20 min for HIG
20 seconds per stretch
8
12
12
10
8
5
10
15
Week 1 and 5 Wednesday
318
Recumbent bike
Elliptical
Treadmill
Rower
Spin bike
Arm crank
stretch quads, hamstrings, stick stretch for shoulder, calves, glutes
Drawing in: long squeezes
Drawing in: quick squeezes
Pull transversus abdominus into spine
Tighten transversus abdominus and pelvic tilt
Floor bridge
Russian twists
Canadian crunches
Quadruped alternate extension
Supine ball rollouts
Wipers
stretch quads, hamstrings, stick stretch for shoulder, calves, glutes
Volume
5 x 3 seconds
10 x 1 second
10 x 5 seconds
5 x 3 seconds in and out
10 x 6 seconds
10
15
12
8
6 / side
Week 1 and 5 Friday
stretch quads, hamstrings, lower back, abs, neck, glutes
Boxing: learn jabs, hooks, upper cuts, seated over head punches, high
jabs, jab-jab-hook combinations
319
Cable twist
Ball cobra
Ball squats
Side plank
Arnold press
Split stance side lunges
Front squat
Single leg toe touches
stretch quads, hamstrings, lower back, abs, neck, glutes
Volume
3 min for both group
4 / side
8
10
3 x 3 seconds
8
5
5
5
Week 2 and 6 Monday
320
Stretch quads, hamstrings, chest, shoulders, triceps, 5 wall crawls
Cable twist
Single leg bosu stand
Theraband rows
Different cardio machine
Leg press
Standing oblique crunches
Bench dips
Volume
5 x 3 seconds
10 x 1 second
10 x 5 seconds
2 x 8 / side
2 x 30 seconds
2 x 20
2 x 10
2 x15 / side
2x6
321
Walk outside
Stretch quads, hamstrings, stick stretch for shoulder, calves, glutes
Medicine ball around body pass
Calf raises
Kneeling rows
Ball squats
Side lying hip abduction
Side raises
Volume
5 x 3 seconds
10 x 1 second
10 x 5 seconds
4 x 8 / way
4 x 15
4 x 12
4 x 12
4 x 15
4 x 12
4 x 10
Week 2 and 6 Friday
Volume
322
Stretch quads, hamstrings, lower back, abs, neck, glutes
Boxing sets: rhythmic punches; high punches rhythmic; jab jab hook
combo, jab jab hook upper cut combo; pyramids 2-20; quick but light
punches;2x30s w/ 15s for combo; reset for pyramids; 45s for quicks
5 x 3 seconds
10 x 1 second
10 x 5 seconds
20 min total for LIG, 16 min total for HIG
Front squat
Single leg stand with eyes closed
Ball cobra
Lat pulldown
Russian twist
8
30 seconds
12
8
8
10 / side
Week 3 and 7 Monday
Volume
323
Laps up and down the stairs
Perform stairs, one set of strength, then repeat
Cable rotational lift
Chest flys
Kneeling rows
Side plank
Y raises
5 x 3 seconds
10 x 1 second
10 x 5 seconds
2 x 5 min
2 x 8 / side
2 x 12
2 x 10
2 x 12
2 x (4 x 5 seconds)
2x8
Volume
324
Walk outside
Single leg multiplaner leg lifts
Ball cobra
Ball squats
Wipers
Arnold Press
Prone ball rollouts
5 x 3 seconds
10 x 1 second
10 x 5 seconds
4x5
4 x 12
4 x 15
4 x 6 / side
4x8
4x8
Week 3 and 7 Friday
325
Jogging laps in water
Arm circles lifting the knees
Jump switch lunges with punches
Jumping jacks
Tricep extension with calf raises
Toe, heel, eversion, and inversion walks
Hip flexion and extension with noodle
Hip abduction and adduction with noodle
Jogging laps in water
Holding edge of pool, flutter kicks
Hands on float board, kicking laps down and back
**Repeat workout as necessary to fill total time in pool
Volume: total time in pool for LIG, 50 minutes; for HIG, 40 minutes
5 min
1 min each direction
1 min
1 min
1 min
1 lap
1 min
1 min
2 min
6 x 10 seconds work with 10s rest
3 laps
Week 4 and 8 Monday
326
Front squat
Bicycle
Push ups
Cross trainer
Russian twist
Rower
Lat pulldowns
Arm crank
Plank
Treadmill
Volume
5 min for both groups
2x8
2x8
2 x 10 / side
2x8
3 x 15 seconds
Volume
327
Cable twist
Single leg bosu stand
Bridge
Theraband rows
Chair squats
Standing side bends
Side raises
Canadian crunches
5 x 3 seconds
10 x 1 second
10 x 5 seconds
4 x 8 / side
4 x 30 seconds / leg
4 x 1 min
4 x 20
4 x 12
4 x 15
4 x 10
4 x 15
Week 4 and 8 Friday
Volume
328
Walk outside
Spin class**
Front squat
Push ups
Ball reverse flys
Russian twists
Arnold press
Leg press
10 min
8
8
15
8
10 / side
12
15
**spin class: 1 minute seated, 1 minute standing, 1 minute seated, 1 minute hovering back, 1 minute seated, 1 minute alternating
seated to standing, 1 minute seated, 1 minute hovering forward, 1 minute seated, 1 minute handlebar push ups
Appendix H. Initial Resistance Training Load Guidelines
329
Specific Exercise and
LIG progressed load /
LIG initial load
HIG progressed load
Repetitions Performed
HIG initial load
Cable twist 8/side
34% BW
44% BW
54% BW
Front squats 8
8% BW
10% BW
13% BW
Total body
Medicine ball around body pass
1.3% BW
1.7% BW
2.2% BW
8/direction
Single leg bosu stand 30
seconds
Single leg multi-planer leg
Balance
raises 5
BW only
Single leg Romanian deadlift 12
Single leg stand with eyes
closed 30 seconds
Canadian crunches 15
Plank 30 seconds
Abdominals
BW only
Prone ball rollouts 8
Supine ball rollouts 8
Bridge 1 minute total
Lower back
BW only
(weights given per
12
arm)
Ball cobra 12
1.3% BW
1.7% BW
2.2% BW
Chest
Push ups 8
BW only
(weights given per
Dips 8
arm)
Chest flys 10
4% BW
5% BW
6% BW
Theraband rows 20
Red
Green
Blue
Reverse flys 15 (weights given
1.3% BW
1.7% BW
2.2% BW
Back
per arm)
Lat pulldowns 8
34% BW
44% BW
54% BW
Kneeling rows 12 (weights
11% BW
14% BW
17% BW
given per arm)
Ball squats 15
10% BW
13% BW
16% BW
Legs
Chair squats 12
BW only
(weights given per
Leg press 15
50% 1RM
65% 1RM
80% 1RM
arm except for leg
Side lying hip abduction 12
BW only
press)
Calf raises 15
4% BW
5% BW
6% BW
Split stance side lunges 8
6.7% BW
8.8% BW
11% BW
Russian twist 10/side
2.7% BW
3.5% BW
4.3% BW
Side plank 20 seconds
BW only
Obliques
Standing side bends 15
6.7% BW
8.8% BW
11% BW
Wipers 6/side
BW only
Arnold press 12
3.9% BW
5.1% BW
6.2% BW
Shoulders
Side raises 10
3% BW
3.9% BW
4.8% BW
Y raises 8
3% BW
3.9% BW
4.8% BW
Note. LIG = lower intensity group; HIG = higher intensity group; BW = body weight; 1RM = one repetition
maximum
Exercise Type
330
Appendix I. CPET calibration procedures
331
At the beginning of each assessment period, the Monark bike wheel and resistance
band were cleaned and checked for damage. The tension was calibrated following the
procedures described in the Monark manual, which is done by hanging a four kilogram
weight from the tension spring and adjusting the meter reading plate to exactly line up the
four kilopond mark with the line on the pendulum.
Prior to use, the metabolic cart was allowed to warm up for 2.5 to 3 hours, until its
temperature was stable. At the start of each week, the metabolic cart’s gas analyzers were
calibrated using two A grade gases (BOC Limited, Canning Vale, Australia) one containing
3.995% CO2 and 16.50% O2, and the other containing 2.488% CO2 and 14.48% O2. The
analyzers were calibrated using the lower saturated A grade gas first, and the higher saturated
one second. After the analyzers were calibrated, a B grade gas tank (BOC limited, mixed at
2.51% CO2 and 14.5% O2) was verified for its accuracy. Immediately prior to every CPET,
the analyzers were readjusted using the B grade gas.
Before the first test of every day, the volume flow on the metabolic cart was
calibrated using a Hans Rudolph Series 5530 3 L syringe (Hans Rudolph Inc, Kansas City,
MO, USA). If testing for the day lasted more than four hours, and / or if there was a break
between tests lasting at least an hour, the volume flow was recalibrated.
332

The effect of exercise intensity on physiological and psychological

Transcription

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