Cancer related fatigue (CRF) is the most common issue affecting cancer survivors, which greatly influences quality of life. While physical activity can alleviate CRF as well as having a positive effect on cancer outcomes, cancer survivors have low rates of physical activity and often cite CRF as a barrier. This study developed an exercise adherence program for breast cancer survivors with moderate or greater CRF, and tested its efficacy. 
Following the IMP protocol, the BLESS program (Better Life after cancer – Energy, Strength, and Support) for exercise adherence was developed as a 12 week, weekly program. The exercise component focused on strengthening core muscles (low, moderate, high intensity) with minimal burden to upper extremities, and small groups focusing on bonding and bridging as social capital components. As a RCT design, the experimental group (n=23) participated in the BLESS program.  Weekly text messages to encourage continuation were sent to both the experimental and the control (n=25) groups. Measurement of exercise adherence, physical, psychosocial, and biological parameters were done at 5 points: baseline (M1) and immediately after (M2) the 12 week program, and 1 month (M3), 6 months (M4), and 12 months (M5) following completion. The comparison group received the exercise component after M2 measurement. Both groups were homogeneous at baseline. There were statistically significant differences in exercise adherence, intention to exercise, CRF, IL-6 and TNF-α, quality of life, menopausal symptoms, and physical endurance and lower muscle strength over time. There were no differences by group and time interaction. This may be related to participants mostly being early survivors (<2 years), who had unmet needs regarding CRF management and exercise, and were highly motivated. Another factor may be the cancer recurrence and death of one participant during the BLESS program, which affected the experimental group. Finally, strategies for translation and dissemination of study findings into practicum were identified, such as linking with the national cancer information center.

 Supportive Care

The 12-week BLESS exercise adherence program consisted of an introductory phase (6 weeks) of supervised small group exercise, followed by an adaptation phase (6 weeks) of home-based exercise. There were a total of 8 face-to-face sessions.

Arm Label

Target Number of Participant

Arm Type

Arm Description

The intervention group participated in a 12-week exercise adherence program, consisting of small group sessions to activate social capital while targeting cancer-related fatigue (CRF) in supervised physical exercises supplemented by home-based physical exercises.

Arm Label

Target Number of Participant

Arm Type

Arm Description

The control group was only given written information on exercise and for follow up periods, craft activities were provided to encourage follow up. Upon completion of the study, the control group was offered an exercise session as a group.

Gender

Age

Description

• Breast cancer stages I-III
• Completion of surgery and chemotherapy
• NRS 4 or greater level of fatigue
• Within 5 years since cancer diagnosis
• At least 6 months past cancer diagnosis

• Underlying factors contributable to fatigue, i.e., cardiovascular disease, thyroid disease
• Recurrent breast cancer or other concurrent cancers
• Diagnosis of panic disorders, schizophrenia, bipolar disease
• Determined unfit for low to moderate level exercise
• Pregnant status
• Those enrolled in regular exercise programs (pilates, yoga, PT, fitness)

GPAQ + walking, exercise adherence (EARS)

Baseline (M1), 12 weeks (M2, post-intervention), 1 month later (M3), 6 months later (M4), 12 months later (M5)

Fatigue (R-PFS)

Baseline (M1), 12 weeks (M2, post-intervention), 1 month later (M3), 6 months later (M4), 12 months later (M5)

QOL (FACT-B)

Baseline (M1), 12 weeks (M2, post-intervention), 1 month later (M3), 6 months later (M4), 12 months later (M5)

Sleep quality (K-PSQI)

Baseline (M1), 12 weeks (M2, post-intervention), 1 month later (M3), 6 months later (M4), 12 months later (M5)

Depression, anxiety (K-HADS); post-traumatic growth (K-PTGI)

Baseline (M1), 12 weeks (M2, post-intervention), 1 month later (M3), 6 months later (M4), 12 months later (M5)

anthropometric measurements

Baseline (M1), 12 weeks (M2, post-intervention), 1 month later (M3), 6 months later (M4), 12 months later (M5)

Serum cytokines

Baseline (M1), 12 weeks (M2, post-intervention), 6 months later (M4)

Anthropometric measurements (BMI, BP, PR, WC, inbody)

Baseline (M1), 12 weeks (M2, post-intervention), 1 month later (M3), 6 months later (M4), 12 months later (M5)

Menopausal symptoms (FACT-ES)

Baseline (M1), 6 months later (M4), 12 months later (M5)

Motivational readiness for exercise (TPB variables)

Baseline (M1), 12 weeks (M2, post-intervention), 1 month later (M3), 6 months later (M4), 12 months later (M5)

Bonding & bridging social capital (PSCS)

Baseline (M1), 12 weeks (M2, post-intervention), 6 months later (M4), 12 months later (M5)

Sociodemographics

Baseline (M1)

Disease-related characteristics

Baseline (M1)

Sue Kim & Yun Hee Ko & Yoonkyung Song & Min Jae Kang & Hyojin Lee & Sung Hae Kim & Justin Y. Jeon & Young Up Cho & Gihong Yi & Jeehee Han. Development of an exercise adherence program for breast cancer survivors with cancer-related fatigue—an intervention mapping approach. Supportive Care in Cancer. SCI. 2019-04-10 ,
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														https://doi.org/10.1007/s00520-019-04785-2
														

Sue Kim & Yun Hee Ko & Yoonkyung Song & Min Jae Kang & Hyojin Lee & Sung Hae Kim & Justin Y. Jeon & Young Up Cho & Gihong Yi & Jeehee Han. Pre-post analysis of a social capital-based exercise adherence intervention for breast cancer survivors with moderate fatigue: a randomized controlled trial. Supportive Care in Cancer. SCI. 2020-02-26 ,
														 VOL : 28 page : 5281 ~ 5289
														https://doi.org/10.1007/s00520-020-05363-7
														

Sue Kim & Jeehee Han &Min Young Lee & Min Kyeong Jang. The experience of cancer-related fatigue, exercise and exercise adherence among women breast cancer survivors: Insights from focus group interviews. Journal of Clinical Nursing. SCI. 2019-11-19 ,
														 VOL : 29 page : 758 ~ 769
														DOI: 10.1111/jocn.15114
														

Sung Hae Kim, Yoon Kyung Song, Jeehee Han, Yun Hee Ko, Hyojin Lee, Min Jae Kang, Hyunki Park, Hyangkyu Lee, Sue Kim. Pro-inflammatory Cytokine Levels and Cancer-related Fatigue in Breast Cancer Survivors: Effects of an Exercise Adherence Program. Journal of Breast Cancer. SCI. 2020-04-23 ,
														 VOL : 23 page : 205 ~ 217
														https://doi.org/10.4048/jbc.2020.23.e22
														

Two performance objectives (survivors adopt and maintain exercise and survivors cope with fatigue) and 17 change objectives were generated. Also, we designed theory-based methods of change, and strategies for practical application. A structured program plan that includes intervention content and methods, ranges, and program data was proposed. Finally, an implementation and evaluation plan was developed.

After participating in BLESS, the CRF behavioral/severity domain significantly decreased (t = 2.642, p = 0.011) and physical activity significantly increased (t = −2.049, p = 0.046) in the intervention group, in comparison with the control group; there were no significant post-intervention differences in the control group. Both groups showed improvements in sleep quality, depression, anxiety, and QOL. The BLESS intervention improved CRF in BCS immediately at post-intervention, and this study presents clinical feasibility for the management of CRF in BCS in the early survivorship phase who are already experiencing fatigue.