Breast cancer (BC) is the most prevalent cancer type in the UK, with one in seven women being diagnosed in their lifetime1. The World Health Organization (WHO) reported that 2.3 million women were diagnosed with BC in 20202. While there has been a significant rise in the occurrence of BC over the past 20 years, the mortality rate has been reduced, in part, by the implementation of screening3.
Yet, although preventative measures provide clinical management before diagnosis, the quality of life (QoL) of BC patients during treatment is deteriorating4. QoL is defined by the WHO as “individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and about their goals, expectations, standards and concerns”5. This encompasses aspects of an individual’s wellbeing, including physical health, psychological status, autonomy, beliefs, and how they interact with their surrounding environment. Physical exercise (PE) benefits and enhances QoL, contributing to positive health – physically, socially and emotionally6.
Furthermore, PE is defined as engaging in movement and activities to maintain one’s physical wellbeing and health7. Incorporation of PE for BC patients could therefore enhance QoL, ensuring better survival and oncological outcomes and focusing on a more holistic patient pathway8⁻10.
Although research has explored the impact of PE on aspects of QoL – such as fatigue, physical function, body composition, strength and metabolic function – for BC patients receiving radiotherapy (RT), there is a scarcity of research on how PE impacts all aspects of QoL. This paper aims to gather insights on various QoL dimensions and identify the most effective and beneficial forms of PE for BC patients to enhance their holistic wellbeing whilst encompassing their survival and oncological outcome.
Furthermore, the systematic review (SR) aims to answer the research question exploring the potential impact of PE on QoL for women receiving RT for BC.
Yet, although preventative measures provide clinical management before diagnosis, the quality of life (QoL) of BC patients during treatment is deteriorating4. QoL is defined by the WHO as “individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and about their goals, expectations, standards and concerns”5. This encompasses aspects of an individual’s wellbeing, including physical health, psychological status, autonomy, beliefs, and how they interact with their surrounding environment. Physical exercise (PE) benefits and enhances QoL, contributing to positive health – physically, socially and emotionally6.
Furthermore, PE is defined as engaging in movement and activities to maintain one’s physical wellbeing and health7. Incorporation of PE for BC patients could therefore enhance QoL, ensuring better survival and oncological outcomes and focusing on a more holistic patient pathway8⁻10.
Although research has explored the impact of PE on aspects of QoL – such as fatigue, physical function, body composition, strength and metabolic function – for BC patients receiving radiotherapy (RT), there is a scarcity of research on how PE impacts all aspects of QoL. This paper aims to gather insights on various QoL dimensions and identify the most effective and beneficial forms of PE for BC patients to enhance their holistic wellbeing whilst encompassing their survival and oncological outcome.
Furthermore, the systematic review (SR) aims to answer the research question exploring the potential impact of PE on QoL for women receiving RT for BC.
Method
An SR was conducted following PRISMA to investigate the effect of PE on the QoL of women receiving RT for BC11. The aim was to recognise unexplored aspects of existing literature and further implement the intervention into practice.
The Boolean operator ‘AND’ was used to shape results, providing a relationship between the search terms and identifying articles most pertinent to the SR13.
All retrieved articles were assessed and classified by theme, which is demonstrated in Table 5. In terms of ethics, all reviewed articles were examined for ethical approval and consideration, adhering to good research practice.
[INSERT flowchart_1 HERE]
[INSERT figure_1 HERE]
Participating in high-intensity football training at 80-90% of maximum heart rate shows no significant changes in overall resting heart rate, which is an aspect of QoL19. However, it is important to note that BC patients undergoing HIIT had improved cardiovascular fitness18. This indicates that the success of differentiating modalities of high-intensity training may have varying impacts on cardiovascular QoL elements of BC patients. In terms of high-intensity training, HIIT consists of short bursts of intense exercise followed by a rest or lower-intensity exercise. This may be more beneficial for BC patients as it is time efficient, improves oxygen uptake, enhances muscle strength and reduces fatigue and psychological symptoms of treatment24. Furthermore, an increase in oxygen uptake improves QoL as it reduces physical deterioration, resulting in a reduction of cancer mortality and improved oncological outcome25.
Both high- and moderate-intensity training are reported to improve differing QoL elements18. Yet a novel idea would suggest that a tailored approach to exercise rehabilitation intervention, that is patient specific, would optimise overall wellbeing and QoL26.
[INSERT table_3 HERE]
[INSERT table_4 HERE]
[INSERT table_5 HERE]
Home-based resistance training and aerobics are safe, feasible and effective when carried out during RT treatment – and not only are they effective at increasing CRF recovery but they also improve QoL31. This concept suggests that smaller amounts of exercise are preferable to those stated in the generic recommendations for BC. Moreover, remote training supports long-term QoL by improving vitality and mental health30. By implicating remote training into the pathway for BC patients, there is an enhancement in psychological status, leading to a positive correlation in terms of oncological outcome and morbidity rates 32,33.
While remote PE may offer advantages to BC patients’ QoL, self-directed exercise carries inherent risks. The overall value of such interventions will vary among individual patients34. The novel concept of integrating remote and home-based PE into the BC patient pathway is currently under investigation and trial, as exemplified by the ongoing TeleCaRe trial35.
Fatigue was measured throughout the review using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) and the Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F) scale 31,40,41,42, Both provide reliable and valid measures for evaluating fatigue43,44.
Less fatigue was observed during RT treatment in those who partake in PE31. However, post-RT treatment (up to six weeks) an increase in fatigue was observed among those who participated in PE31,42. Conclusions were drawn that general fatigue among BC patients increases over time after treatment42.
In contrast, multimodal exercise in particular was noted for reducing fatigue45. It is theorised that continuous muscle contraction and relaxation promote vasodilation, increasing blood circulation, respiration and, therefore, energy expenditure whilst releasing endorphins that contribute to an improved psychological state46. This provides insight as to why PE showed clinical improvement in reducing mental fatigue 41,42. Therefore, multimodal exercise mobilises PE, focusing on the motion of movement, preventing rest through mental distraction47. Consequently, multimodality exercises may be a preferred form of PE in terms of enhancing QoL and reducing fatigue of BC patients undergoing RT.
Specific characteristics were identified as contributing to fatigue levels within the review. For example, participants with an unhealthy body mass index (BMI) who underwent PE intervention improved in physical fatigue, whilst those who lived alone improved in mental fatigue 41. In addition, BC patients presenting with signs of fragility should be closely monitored for fatigue levels during RT treatment and provided with PE-related supportive care42. By focusing on these particular demographics, PE interventions can play a role in supporting the overall patient pathway.
Following RT treatment, both immediately and six weeks post-treatment, higher levels of fatigue were correlated with increased perceived exertion rating during resistance training and lower levels of fatigue were associated with longer durations of weekly aerobic exercise 31. This suggests longer sessions of PE with a greater resting period are beneficial, providing improvement in fatigue, energy and vitality, all of which are factors of QoL48.
Moreover, deterioration of psychological and physiological aspects of QoL in BC patients are likely to take place after treatment 52,53,54. Through PE intervention, long-term improvement in mental health is achieved 30. While PE may improve long-term psychological wellbeing, questions remain about maintaining these behaviours over time. This emphasises the importance of focusing on the emotional wellbeing of BC patients with lower emotional functioning49.
In addition, physical activity decreased significantly six months after RT41. This, moreover, highlights the need for follow-up appointments on BC patients’ QoL to gain insight into how PE affects long-term QoL41. A factor that plays a role in reducing the carrying out of QoL assessments is unwillingness due to logistical problems, such as limited resources and time55. However, it is imperative to incorporate long-term QoL evaluations of BC patients and engage with participants after interventions to ensure their perspectives are integrated into future programmes and that the long-term effect can be measured. By actively involving patients in the assessment process, unique experiences and insights can be considered. This highlights a more holistic approach and the collaborative effect not only acknowledges person-centred needs but fosters inclusivity within the programme, enhancing the QoL support provided 56.
A population study indicated that improved lifestyle and dietary habits were associated with reduced overall mortality rates following the diagnosis of BC58. For instance, the intake of fruit and vegetables and a reluctance to eat high-fat food was observed in PE groups59. This suggests food intake and PE could be positively correlated, resulting in favourable outcomes of QoL.
Nutrition is a crucial factor throughout the BC patient’s pathway. Incorporating dietary guidance in conjunction with PE, involving physiotherapists and sports therapists, demonstrates an MDT approach focusing on the holistic wellbeing of the patient. This helps prevent treatment side effects. Evidence-based guidelines on cancer prevention through nutrition and PE should be included in treatment protocols. A person-centred approach with personalised guidance from nutritionists and physiotherapists can tailor recommendations to specific side effects or QoL factors 61.
Barriers hindering the implementation of nutritional therapy in BC patients include a lack of valid and reliable evidence62. The formation of multidisciplinary medical teams, effective collaboration between oncologists and nutritionists, and the integration of education within the speciality can address these challenges 63.
Furthermore, multimodal exercises effectively reduce fatigue and improve QoL. Tailored exercise programmes optimise overall QoL, with long-term benefits in physical, role, cognitive functions and fatigue. Combining nutritional and PE support for BC patients undergoing RT shows promising results in enhancing QoL.
Future studies could explore the optimal form of delivery methods of PE for BC patients during RT as well as determine the most suitable modality for individualised, person-centred care. ■
Pilot search
A pilot search was conducted in March 2023 to ascertain how feasible a study would be. This was beneficial as it allowed for a sample search in advance to test how feasible or acceptable the study might be on a larger scale12. Search terms were extracted from the research question: ‘physical exercise’, ‘breast cancer’, ‘radiotherapy’ and ‘quality of life’. These were filtered to articles published at any time and later refined to 10, five and two years as well as since 2023. Other key terms ‘menopausal’, ‘pre-menopausal’, ‘resistance training’ and ‘aerobic training’ were additionally filtered. The number of articles and refinements are demonstrated in Table 1.Search terms
In March 2024, the search terms: ‘physical exercise’, ‘breast cancer’, ‘radiotherapy’ and ‘quality of life’ were entered into PubMed, Cochrane Library, Ovid and AMED.The Boolean operator ‘AND’ was used to shape results, providing a relationship between the search terms and identifying articles most pertinent to the SR13.
| Search terms | Time of article publication | Total number of articles |
|---|---|---|
| Physical exercise, breast cancer, radiotherapy and quality of life | Any time | 86,400 |
| Physical exercise, breast cancer, radiotherapy and quality of life | 2013-2023 | 17,600 |
| Physical exercise, breast cancer, radiotherapy and quality of life | 2018-2023 | 17,400 |
| Physical exercise, breast cancer, radiotherapy and quality of life | 2022-2023 | 17,300 |
| Physical exercise, breast cancer, radiotherapy and quality of life | Since 2023 | 3,670 |
| Physical exercise, breast cancer, radiotherapy, quality of life and menopause or menopausal | Any time | 85,100 |
| Physical exercise, breast cancer, radiotherapy, quality of life and pre-menopausal | Any time | 5,960 |
| Physical exercise, breast cancer, radiotherapy, quality of life and resistance training | Any time | 29,600 |
| Physical exercise, breast cancer, radiotherapy, quality of life and aerobic exercise | Any time | 23,500 |
Search criteria and screening process
Articles were selected using the inclusion and exclusion criteria outlined in Table 2, and phase-one screening was carried out, demonstrated in Flowchart 1. Duplicates and outstanding SRs were eliminated from the results to avoid the introduction of bias into primary research14. The selected articles were then further screened in concordance with their relevance to the search terms, displayed in Figure 1. Phase-two screening was carried out, implicating the Critical Appraisal Skills (CASP) checklist15. This was to further infer the inclusion and exclusion criteria and assess the quality appraisal of articles16.All retrieved articles were assessed and classified by theme, which is demonstrated in Table 5. In terms of ethics, all reviewed articles were examined for ethical approval and consideration, adhering to good research practice.
| Inclusion criteria | Exclusion criteria | |
|---|---|---|
| Date | Only articles published between 2019 and 2024 will be used because they are more time bound. | Any articles not published within this period will be excluded, given that they will not be as closely related to or relevant to the present population. As well as this, practice evolves and changes so current data is needed. |
| Full text | Articles that contain the full text and so the full data. This is to avoid misinterpretation due to loss of data that may have been excluded. This reduces the chance of bias. | Articles that do not contain full text cannot be analysed given they lack the in-depth information that is necessary for the study to be valid and so reliable. |
| Language | Only English-language articles will be used so reliability can therefore be accurately assessed. | Any non-English-language articles will be excluded given that this opens the systematic review up to transcription errors which could lead to raw data being invalid. |
| Patient diagnosis | Only breast cancer patients will be used as exercise may affect other diagnosis differently. | Non-breast cancer diagnosis will be excluded as results may differ to the initial research question. |
| Peer reviewed | All articles included must be peer reviewed, this reduces the chance of bias. | Articles that have not been peer reviewed as they could be deemed unreliable. |
| Treatment type | Patients undergoing RT and other cancer treatments will be included as this ensures the same variable is being tested. | Those not undergoing any RT at all will be excluded as this will be invalid. |
[INSERT flowchart_1 HERE]
[INSERT figure_1 HERE]
Results
Seventy three articles were found within the search, whereby 35 full-text articles were reviewed (Table 3 and Table 4) and 13 were analysed (Table 5).Discussion
The following subheadings were extracted from themes identified in the reviewed articles summarised in Table 6, allowing for analysis to obtain an understanding of behaviours across a data set17.Level of intensity
The intensity of PE is extensively explored in the reviewed literature. Discussions encompass moderate and high-intensity training, including cardiorespiratory fitness, high-intensity interval training (HIIT), moderate-intensity continuous training (MICT), resistance training and aerobics, all in relation to QoL aspects18⁻21. Engaging in moderate-intensity exercise with a focus on aerobics has shown yield in significant benefit across QoL but also contributes to positive adaptations in body weight and composition as well as muscular strength20,21. Furthermore, physical wellbeing is improved significantly by 95% when BC patients undergoing RT take part in continuous training18. This underscores the potential of long-term enhancement of QoL through BC patients’ participation in PE. Additional data indicates that elements of QoL, such as improved sleep quality, alleviated anxiety and depression, can be gained through engagement in moderate intensity PE, mirroring the reviewed article findings22. As these studies were conducted within a clinical setting, the implications for practice suggest that such rehabilitative support could additionally be provided for BC patients, improving effectiveness and efficiency of healthcare23.Participating in high-intensity football training at 80-90% of maximum heart rate shows no significant changes in overall resting heart rate, which is an aspect of QoL19. However, it is important to note that BC patients undergoing HIIT had improved cardiovascular fitness18. This indicates that the success of differentiating modalities of high-intensity training may have varying impacts on cardiovascular QoL elements of BC patients. In terms of high-intensity training, HIIT consists of short bursts of intense exercise followed by a rest or lower-intensity exercise. This may be more beneficial for BC patients as it is time efficient, improves oxygen uptake, enhances muscle strength and reduces fatigue and psychological symptoms of treatment24. Furthermore, an increase in oxygen uptake improves QoL as it reduces physical deterioration, resulting in a reduction of cancer mortality and improved oncological outcome25.
Both high- and moderate-intensity training are reported to improve differing QoL elements18. Yet a novel idea would suggest that a tailored approach to exercise rehabilitation intervention, that is patient specific, would optimise overall wellbeing and QoL26.
[INSERT table_3 HERE]
[INSERT table_4 HERE]
[INSERT table_5 HERE]
| Theme | Article |
|---|---|
| Level of intensity | Carpenter et al. (2024), Kirkham et al. (2019), Isanejad et al. (2023) and Uth et al. (2020) |
| Remote training | Dong et al. (2019), Dong et al. (2020) and Mavropalias et al. (2023) |
| Fatigue | Zhang et al. (2023), Mavropalias et al. (2023), Adams-Campbell et al.(2023), Jacot et al. (2020) and Gjerset et al. (2023) |
| Long-term QoL | Dong et al. (2020), Gjerset et al. (2023), Kokkonen et al. (2022) and Uth et al. (2020) |
| PE and diet interaction | Ahn et al. (2020) and Jacot et al. (2020) |
Remote training
Internet-based rehabilitation applications with guidance and exercise programmes are now available to BC patients to improve their QoL27,28. Research has shown that by incorporating remote training, via online applications, QoL factors such as muscle strength, cancer-related fatigue (CRF), cardiopulmonary endurance and engagement in physical activity improved 29,30,31.Home-based resistance training and aerobics are safe, feasible and effective when carried out during RT treatment – and not only are they effective at increasing CRF recovery but they also improve QoL31. This concept suggests that smaller amounts of exercise are preferable to those stated in the generic recommendations for BC. Moreover, remote training supports long-term QoL by improving vitality and mental health30. By implicating remote training into the pathway for BC patients, there is an enhancement in psychological status, leading to a positive correlation in terms of oncological outcome and morbidity rates 32,33.
While remote PE may offer advantages to BC patients’ QoL, self-directed exercise carries inherent risks. The overall value of such interventions will vary among individual patients34. The novel concept of integrating remote and home-based PE into the BC patient pathway is currently under investigation and trial, as exemplified by the ongoing TeleCaRe trial35.
Fatigue
Fatigue is defined as an extreme sense of exhaustion and lack of energy that causes an interference with one’s usual daily activities36. More specifically, CRF is a distressing and persistent form of fatigue that is related to cancer or cancer treatment37. Within the review, these symptoms were commonly referred to and can determine and adjust cancer prognosis and treatment outcomes, hence holding importance when supporting QoL38,39.Fatigue was measured throughout the review using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) and the Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F) scale 31,40,41,42, Both provide reliable and valid measures for evaluating fatigue43,44.
Less fatigue was observed during RT treatment in those who partake in PE31. However, post-RT treatment (up to six weeks) an increase in fatigue was observed among those who participated in PE31,42. Conclusions were drawn that general fatigue among BC patients increases over time after treatment42.
In contrast, multimodal exercise in particular was noted for reducing fatigue45. It is theorised that continuous muscle contraction and relaxation promote vasodilation, increasing blood circulation, respiration and, therefore, energy expenditure whilst releasing endorphins that contribute to an improved psychological state46. This provides insight as to why PE showed clinical improvement in reducing mental fatigue 41,42. Therefore, multimodal exercise mobilises PE, focusing on the motion of movement, preventing rest through mental distraction47. Consequently, multimodality exercises may be a preferred form of PE in terms of enhancing QoL and reducing fatigue of BC patients undergoing RT.
Specific characteristics were identified as contributing to fatigue levels within the review. For example, participants with an unhealthy body mass index (BMI) who underwent PE intervention improved in physical fatigue, whilst those who lived alone improved in mental fatigue 41. In addition, BC patients presenting with signs of fragility should be closely monitored for fatigue levels during RT treatment and provided with PE-related supportive care42. By focusing on these particular demographics, PE interventions can play a role in supporting the overall patient pathway.
Following RT treatment, both immediately and six weeks post-treatment, higher levels of fatigue were correlated with increased perceived exertion rating during resistance training and lower levels of fatigue were associated with longer durations of weekly aerobic exercise 31. This suggests longer sessions of PE with a greater resting period are beneficial, providing improvement in fatigue, energy and vitality, all of which are factors of QoL48.
Long-term QOL
The review encompasses studies that employ varying durations of follow-up and long-term QoL assessments. For instance, some took place six months to a year later19,30,41 while others took place up to five years49 later. There is a small amount of data determining the long-term effects of PE on the QoL of BC patients undergoing RT. Despite this, subscales of function – physical, role and cognitive – as well as fatigue were reported to improve after intervention of PE41,30,50. This reveals that neurological changes take place due to the takeup of PE by BC patients51.Moreover, deterioration of psychological and physiological aspects of QoL in BC patients are likely to take place after treatment 52,53,54. Through PE intervention, long-term improvement in mental health is achieved 30. While PE may improve long-term psychological wellbeing, questions remain about maintaining these behaviours over time. This emphasises the importance of focusing on the emotional wellbeing of BC patients with lower emotional functioning49.
In addition, physical activity decreased significantly six months after RT41. This, moreover, highlights the need for follow-up appointments on BC patients’ QoL to gain insight into how PE affects long-term QoL41. A factor that plays a role in reducing the carrying out of QoL assessments is unwillingness due to logistical problems, such as limited resources and time55. However, it is imperative to incorporate long-term QoL evaluations of BC patients and engage with participants after interventions to ensure their perspectives are integrated into future programmes and that the long-term effect can be measured. By actively involving patients in the assessment process, unique experiences and insights can be considered. This highlights a more holistic approach and the collaborative effect not only acknowledges person-centred needs but fosters inclusivity within the programme, enhancing the QoL support provided 56.
PE, diet and interaction
Throughout the review, the significance of diet and nutritional intake in relation to PE was noted consistently in the context of the QoL of BC patients undergoing RT. The combination of PE and dietary support has led to weight loss in BC patients post-RT, improving their QoL57. This conveys the need for diet counselling and education on balanced dietary intake for BC patients undergoing RT42.A population study indicated that improved lifestyle and dietary habits were associated with reduced overall mortality rates following the diagnosis of BC58. For instance, the intake of fruit and vegetables and a reluctance to eat high-fat food was observed in PE groups59. This suggests food intake and PE could be positively correlated, resulting in favourable outcomes of QoL.
Nutrition is a crucial factor throughout the BC patient’s pathway. Incorporating dietary guidance in conjunction with PE, involving physiotherapists and sports therapists, demonstrates an MDT approach focusing on the holistic wellbeing of the patient. This helps prevent treatment side effects. Evidence-based guidelines on cancer prevention through nutrition and PE should be included in treatment protocols. A person-centred approach with personalised guidance from nutritionists and physiotherapists can tailor recommendations to specific side effects or QoL factors 61.
Barriers hindering the implementation of nutritional therapy in BC patients include a lack of valid and reliable evidence62. The formation of multidisciplinary medical teams, effective collaboration between oncologists and nutritionists, and the integration of education within the speciality can address these challenges 63.
Conclusion
In conclusion, the reviewed literature explores the relationship between PE and QoL for BC patients undergoing RT. Moderate-intensity exercise, such as aerobic exercise, has shown significant benefits across various QoL factors, including body weight, body composition and muscular strength, whilst continuous training during RT treatment has been shown to improve physical wellbeing. HIIT may be particularly advantageous for BC patients because it efficiently improves cardiovascular fitness whilst also allowing for rest periods. Remote training through internet applications also improves QoL factors and may provide future implementation in practice due to its effectiveness.Furthermore, multimodal exercises effectively reduce fatigue and improve QoL. Tailored exercise programmes optimise overall QoL, with long-term benefits in physical, role, cognitive functions and fatigue. Combining nutritional and PE support for BC patients undergoing RT shows promising results in enhancing QoL.
Future studies could explore the optimal form of delivery methods of PE for BC patients during RT as well as determine the most suitable modality for individualised, person-centred care. ■
Use this article for CPD
Reflect on the article and scan the QR code below to record your learning on CPD Now.- How could you integrate both moderate and high-intensity PE into the rehabilitation pathways of BC patients and what factors would guide your choices?
- How could you implement remote PE in your practice for BC patients and what challenges might arise?
- What strategies could you use to address CRF in BC patients and how would you assess their effectiveness?
About the author
Lily-May Jeavons is a Therapeutic Radiographer at Poole Hospital in the University Hospitals Dorset NHS Foundation Trust. She would like to acknowledge the support of her supervisors for this article, Dr Julie Hendry and Chandini Kumari-Webster.
