Outcomes for breast cancer survivors with metastatic disease in a physical activity program for medically underserved cancer survivors

Abstract

Purpose:

This study examined the effectiveness and feasibility of the Active Living After Cancer (ALAC) program for metastatic breast cancer (MBC) survivors.

Methods:

ALAC is a 12-session community-based program to help cancer survivors improve their physical functioning and quality of life through increased physical activity. ALAC participants with MBC (stage IV) were compared to survivors with early-stage breast cancer (stage I and II). The International Physical Activity Questionnaire, Godin Leisure-Time Physical Activity, 30-second sit-to-stand, and PROMIS Global Health were administered at baseline and follow-up. Program satisfaction and retention were assessed at Week 12. Repeated measures mixed models were used to compare changes in outcomes between survivors with early-stage breast cancer and MBC.

Results:

A total of 585 women (59.3 y ± 10.6), most of whom were Hispanic (54%) or non-Hispanic Black (22%), were included (early stage, n=538; MBC, n=47). After the ALAC program, a significant increase in physical activity (P<0.001), improved physical and mental health T-scores (P<0.001), and more sit-to-stand repetitions (p<0.001) were observed for both survivors with early-stage breast cancer and MBC. Women with MBC showed significantly lower physical health (P=0.037) and physical function (P=0.010) compared to early-stage at baseline.

Conclusions:

The ALAC program increased physical activity and improved health-related quality of life and physical function among breast cancer survivors with both early-stage and metastatic disease.

Implications for Cancer Survivors:

This study emphasizes the importance of incorporating physical activity interventions like the ALAC program into the comprehensive care of cancer survivors, including those with metastatic disease.

INTRODUCTION

Patients living with metastatic cancer are a growing proportion of cancer survivors [1]. About 5% to 10% of breast cancers are metastatic at diagnosis, and 20% to 30% of patients with a diagnosis of breast cancer will develop metastases [2]. As treatment options improve, patients with metastatic breast cancer (MBC) are living longer [3], driving the need to examine their health-related quality of life (HRQOL) and physical function. The HRQOL of patients with MBC is characterized by physical and psychological impairments, such as fatigue, pain, depression, and anxiety [4, 5]. Since cancer survivorship refers to the time from cancer diagnosis through end-of-life [1], cancer survivorship research has extended to include patients with metastatic disease.

Physical activity improves several health outcomes of cancer survivors, including physical function, fatigue, and HRQOL [6–8]. Among women with advanced breast cancer and those with early-stage breast cancer, moderate-to-vigorous physical activity (MVPA) is significantly associated with longer disease-free and overall survival [9–12]. Regular exercise following guidelines helps to maintain and improve physical function and HRQOL in people with bone metastases [13]. However, the feasibility and effectiveness of exercise and physical activity programs for survivors with MBC have not been fully elucidated [14–17], as those with metastatic disease are typically excluded from exercise intervention trials because of concerns about safety and side effects, such as pain and fatigue. Previous studies examining the feasibility of exercise and physical activity programs for patients with MBC found poor adherence to exercise recommendations [18], lower exercise tolerance, and the need for exercise dose modifications due to fatigue or pain [17]. In addition, these programs neither improved physical function [16] nor reduced fatigue [14] among patients with advanced breast cancer. This contrasts with studies of early-stage survivors which have shown that exercise improves fatigue, physical function, quality of life, and psychological distress. Thus, the acceptability, feasibility, and efficacy of a particular program approach may be different for survivors with metastatic disease and early-stage disease. Given that patients with MBC express interest in engaging in exercise and physical activity intervention programs [19], studies are required to examine the feasibility and safety of physical activity interventions for survivors with metastatic disease. In addition, survivors with MBC may have unique clinical characteristics and different treatment goals and outcomes compared to survivors with early-stage breast cancer, which suggests a need investigate the effectiveness of programs across cancer stage.

Therefore, the purpose of this study was to examine the effects of a community physical activity program on HRQOL and physical function as well as program retention and satisfaction among racial/ethnic minorities and medically underserved survivors with MBC compared to survivors with early-stage breast cancer. We hypothesized that a community physical activity program would increase physical activity and improve health outcomes in both survivors with early-stage breast cancer and MBC. We also hypothesized that program retention and satisfaction would differ among early-stage breast cancer survivors and those with metastatic disease.

METHODS

Study Design

This study is a secondary analysis of the data from the Active Living After Cancer (ALAC) program (2013–2022). ALAC, an evidence-based lifestyle physical activity program, was developed and implemented to increase physical activity and improve the physical function and HRQOL of cancer survivors, with a focus on outreach to minority and medically underserved communities [20]. ALAC is delivered by community health educators working in communities in Houston, El Paso, Beaumont, and Tyler, Texas. The University of Texas MD Anderson Cancer Center (MD Anderson) in Houston developed the ALAC program and partners with the Kelsey Research Foundation of Houston, the Cancer and Chronic Disease Consortium of El Paso, The University of Texas Health Science Center in Tyler, and Gift of Life in Beaumont to implement the program in the community. The evaluation of the ALAC program was approved by the institutional review board of MD Anderson (PA160398).

Participants

In this analysis we include ALAC participants who participated between 2013 and 2023. ALAC participants are recruited through health care and community organizations (i.e., support groups, community events, health fairs, and patient outreach at churches, cancer survivor clinics, and health care and community organizations). Survivors who were interested in the program were screened for the following eligibility criteria: Survivors who 1) were at least 18 years old, 2) completed their primary cancer treatment (with an exception for survivors who were currently receiving hormonal treatment and survivors with metastatic disease, who were eligible to participate with approval from their health care provider), 4) had medical clearance using the Physical Activity Readiness Questionnaire (PARQ) [21] or health care provider release, and 5) were able to participate in an physical activity program using the PARQ. Details of recruitment and ALAC participants are described elsewhere [20].

In this secondary analysis, we included cancer survivors with breast cancer only; eligible participants were categorized into survivors with 1) early-stage breast cancer (stage I and II) and 2) MBC (stage IV). Stage was assessed by participant self-report. Patients with stage III breast cancer were not included in this study because the disease is neither metastatic nor early-stage (stage III tumors are larger than 50 mm and have regional spread).

Intervention

The group-based 12-week ALAC program aimed to increase participants’ physical activity to 30 or more minutes of MVPA per day and 150 or more minutes of MVPA per week. Program sessions are delivered weekly (one per week) by trained health educators from implementation sites. In the sessions, participants are educated on cognitive and behavioral skills to increase MVPA using goal setting and self-monitoring, among other activities. Each session includes behavioral skill trainings (40 minutes), a brief bout of activity (10–15 minutes), and survivorship topic discussion (25–30 mins). Additionally, health educators and participants (7–15 cancer survivors per group) complete a brief activity. Detailed intervention information is described elsewhere [20].

Measures

Participants provided basic demographic information, such as age, race, educational level, and marital status, and health information, such as cancer type, stage, and treatment.

The physical and mental domains of HRQOL were assessed at baseline and follow-up using the Patient-Reported Outcomes Measure Information System (PROMIS) Global-10 short form [22, 23]. The 10-item questionnaire asks questions related to overall physical, mental, and social health as well as pain, fatigue, and perception of quality of life. T-score was used for the analyses and interpretation.

Physical function was measured at baseline and follow-up by research staffs using a 30-second sit-to-stand test [24], which assesses lower body strength in older adults. Participants were asked to stand up from and sit down on an armless chair as many times as possible in 30 seconds, and the number of repetitions was recorded.

MVPA was assessed at baseline and follow-up using the International Physical Activity Questionnaire (IPAQ) [25] in study phases 1 and 2 (2014–2017) and the Godin Leisure-Time Exercise Questionnaire [26] in study phases 2 and 3 (2017–2023). For both instruments, participants provided the duration of their walking or more vigorous activities and the frequency of each activity over the past 7 days. Total weekly minutes of MVPA were then calculated by multiplying the frequency and duration of activities.

Program retention and satisfaction were assessed after program completion using recorded program attendance and a survey, respectively. The survey assessed the participants’ overall satisfaction with the program using a 5-point Likert scale (1=extremely dissatisfied; 2=dissatisfied; 3=neutral; 4=satisfied; and 5=extremely satisfied) and open-ended comments.

Statistical Analyses

All statistical analyses were performed using STATA 15.1 (StataCorp LP, College Station, Texas). Descriptive statistics were used to summarize the baseline characteristics of the participants. Baseline comparisons of HRQOL, physical function, and physical activity among survivors with MBC and those with early-stage breast cancer were examined using one-way ANOVA tests. Changes in HRQOL, physical function, and physical activity between baseline and follow-up among the groups were analyzed using repeated-measures linear mixed models, controlling for study phases. Differences in the number of program sessions attended among groups were tested using one-way ANOVA. Differences in program satisfaction among the groups were tested using the Pearson chi-square test. Results of analyses were reported using mean and standard deviation (SD) or an unstandardized beta (β) with a standard error (SE), 95% of confidence interval (CI), and P-value (P<0.05 was considered statistically significant).

RESULTS

A total of 585 breast cancer survivors who completed the ALAC program between 2013 and 2023, including baseline and follow-up assessments (questionnaires and sit-to-stand test), were included in the analyses (participants with early-stage breast cancer, n=538; participants with MBC, n=47). Baseline demographic data are described in Table 1. There were no significant differences between the early-stage breast cancer and MBC survivor groups.

Table 1.

Demographic characteristics, n (%)

	TOTAL (N=585)	EARLY-STAGE (N=538)	METASTATIC (N=47)	P-VALUE*
Age, mean (SD), y	59.3 (10.6)	59.4 (10.6)	59.0 (10.9)	0.818
Race and ethnicity
Non-Hispanic White	108 (18%)	99 (18%)	9 (19%)	0.938
Non-Hispanic Black	126 (22%)	117 (22%)	9 (19%)
Hispanic	318 (54%)	291 (54%)	27 (58%)
Other	33 (6%)	31 (6%)	2 (4%)
Marital status
Single	72 (12%)	69 (13%)	3 (6%)	0.060
Married/cohabiting	347 (59%)	322 (60%)	25 (53%)
Divorced/separated	96 (17%)	82 (15%)	14 (30%)
Widowed	70 (12%)	65 (12%)	5 (11%)
Education #				0.297
High school or less	199 (34%)	181 (34%)	18 (40%)
Technical/vocational	58 (10%)	51 (10%)	7 (16%)
Some college	116 (20%)	110 (21%)	6 (13%)
Bachelors degree	116 (20%)	108 (20%)	8 (18%)
Masters degree or higher	90 (15%)	84 (16%)	6 (13%)
Treatment				0.207
Chemotherapy	369 (63%)	329 (62%)	40 (85%)
Radiation	414 (71%)	375 (70%)	39 (83%)
Surgery	513 (88%)	473 (88%)	40 (85%)
Hormone therapy	276 (47%)	262 (49%)	14 (30%)
No treatment	4 (1%)	4 (1%)	0 (0%)
No answer	2 (1%)	1 (1%)	0 (0%)

^*One-way ANOVA tests were used for continuous variable (age) analysis, and Pearson chi-squared tests were used for categorical variables (race, marital status, education, and treatment).

^#Data were missing for 4 patients with early-stage breast cancer and 2 patients with MBC.

Table 2 shows baseline differences in HRQOL, physical function, and MVPA between early-stage breast cancer and MBC survivors. The T-score of physical health domain of HRQOL was significantly lower for MBC survivors (95% CI [44.6, 45.7], P=0.036) compared to early-stage breast cancer survivors. In addition, the mean number of repetitions for the sit-to-stand test for survivors with early-stage breast cancer was 12.7, while that for women with MBC was 10.9, indicating that physical function was significantly lower at baseline for survivors with MBC than those with early-stage breast cancer (95% CI [12.2, 12.8], P=0.004).

Table 2.

Baseline differences of HRQOL, PF, and physical activity between the groups

	TOTAL	EARLY-STAGE	METASTATIC	P-VALUE*
Quality of life (T-score)
Physical health	45.1 (SD=6.9)	45.3 (SD=6.8)	43.1 (SD=6.9)	0.036
Mental health	48.0 (SD=7.1)	48.1 (SD=7.1)	46.3 (SD=7.1)	0.097
Physical functioning
Sit-to-stand test (repetitions/30 s)	12.5 (SD=4.1)	12.7 (SD=4.1)	10.9 (SD=4.1)	0.004
Physical activity
Godin MVPA minutes1	112.0 (SD=125.8)	110.7 (SD=124.3)	127.4 (SD=143.0)	0.502
IPAQ MVPA minutes2	235.5 (SD=339.4)	247.7 (SD=350.2)	110.4 (SD=149.9)	0.064

^*One-way ANOVA tests.

¹During the study phase 2 & 3, participants’ physical activity was assessed using Godin leisure-time moderate-to-strenuous physical activity: all participants=387, participants with early-stage breast cancer=357, and participants with metastatic breast cancer=30

²During phase 1 & 2, participants’ physical activity was assessed using IPAQ MVPA: all participants=260, participants with early-stage breast cancer=237, and participants with metastatic breast cancer=23

HRQOL, health-related quality of life; PF, physical function; MVPA, moderate-to-vigorous physical activity; IPAQ, International Physical Activity Questionnaire.

Changes in HRQOL, physical function, and physical activity among the groups after the ALAC program are presented in Figure 1. HRQOL scores for both the physical and mental health domains improved after the intervention in both groups (physical health: early stage, = +1.5; MBC, +1.4; mental health: early stage, +1.5; MBC, +0.8). There were significant increases over time for both groups combined (physical health: β=1.47, SE=0.24, 95% CI [1.00, 1.93], P<0.001; mental health: β=1.51, SE=0.25, 95% CI [1.03, 1.99], P<0.001). Significant group difference between survivors with early-stage breast cancer and those with MBC were found for physical health domain (β=−2.14, SE=1.02, 95% CI [−4.15, −0.13], P=0.037). However, there was not a significant group by time interaction (physical health: β=0.01, SE=0.84, 95% CI [−1.64, 1.64], P=0.999; mental health: β=−0.75, SE=0.87, 95% CI [−2.45, 0.95], P=0.389). Physical function improved in both groups after the ALAC program (early stage, +2.9 repetitions; MBC, +3 repetitions) and it significantly increased over time (β=2.89, SE=0.17, 95% CI [2.57, 3.23], P<0.001), and the group difference was significant (β=−1.79, SE=0.69, 95% CI [−3.15, −0.43], P=0.010). However, there was not a significant group by time interaction (β=0.10, SE=0.59, 95% CI [−1.06, 1.26], P=0.863). The percent who above the 50^th percentile of sit-to-stand for age and gender in early-stage and MBC were 55% to 38% at baseline and 76% and 77% at follow-up, respectively. MVPA determined by IPAQ (early stage, +176.5 min; MBC, +191.9 min) and Godin leisure-time physical activity (early stage, +168.5 min; MBC, +113.3 min). There were significant increases over time for both groups combined for MVPA by IPAQ (β=176.5, SE=29.04, 95% CI [119.56, 233.39], P<0.001) and Godin leisure-time physical activity (β=168.51, SE=19.94, 95% CI [129.44, 207.59], P<0.001), but there was not a significant group by time interaction (IPAQ: β=15.37, SE=97.62, 95% CI [−175.96, 206.69], P=0.875; Godin: β=−55.23, SE=61.32, 95% CI [−175.41, 64.96], P=0.368). The percent who met recommendation (150 mins/week) in early-stage and MBC was 32% and 39% at baseline, and 66% and 50% after program, respectively.

Figure 1.

Changes in HRQOL, physical function, and physical activity

HRQOL, health-related quality of life; MVPA, moderate-to-vigorous physical activity; IPAQ, International Physical Activity Questionnaire; ¹Significant baseline-to-follow up difference (p<0.05); ²Significant group difference (p<0.05)

Program retention and satisfaction among the groups are described in Figure 2. The mean number of sessions attended was 10 (out of 12) for the early-stage breast cancer group and 9.6 for the MBC group, which was not statistically significant difference (P=0.145). More survivors with early-stage breast cancer were satisfied with the ALAC program compared to survivors with MBC (early stage, 98.9% vs. MBC, 95.7%), which was not statistically significant difference (P=0.075) and satisfaction was high overall. Some of participants with MBC also provided their comments about the program, which are presented in Table 3.

Figure 2.

Program retention and satisfaction

¹One-way ANOVA test; ²Pearson’s chi-squared test

Table 3.

Comments from women with MBC about the ALAC program

I loved the program and I know this has and will continue to help many. I am interested in the second course to get more intense to learn about keep cancer out of the body. To learn and understand that there is a new normal life of living. Many didn’t understand the mental issues of this sickness (43-year-old, Hispanic). (I need) More time! I thank y’all so much! Dr. Reba suggested this class was going to help me and it did because I wasn’t doing exercise, bad eating habits, can’t sleep at night, now I’m exercising, getting better eating habits and now I’m sleeping better at night (58-year-old, non-Hispanic white). I am not as angry and have fewer episodes of anger. I feel better emotionally and am going to join a support group for stage 4 to help me emotionally (52-year-old, non-Hispanic Black). Many thanks to (instructors) for this valuable Workshop they taught. It helped us survivors a lot so that with physical activity we can have a healthier life (52-year-old, Hispanic). I thank the ACTIVE LIVING AFTER CANCER program. Excellent information for me, it helped me be more active and with fewer lazy days, since the step counter helped me make my days more active, it was a challenge for me (41-year-old, Hispanic). I really enjoyed attending ALAC! I benefit from it because it helped me to focus and redirect my energy to improve my physical and mental being. I enjoyed the various presentations by the instructors. They were kind, friendly and knowledgeable. I felt comfortable during each session. This experience is a life changing one because I now know that I can overcome every physical or mental barrier by observing what they are and making adjustments to my life style. Very good program! Thank you! (61-year-old, Asian) Thanks for this workshop. It helps us better understand all the side effects after having undergone a cancer diagnosis. Thanks (instructors) for your dedication to your work and your desire to help us (74-year-old, Hispanic). It was difficult to fully engage in activities because I was diagnosed with cancer again (52-year-old, non-Hispanic Black). It helped me a lot, both physically and emotionally. And very grateful to Isabel for inviting me to the ‘Active Life after Cancer’ workshop (63-year-old, Hispanic women). The program made me more aware of my activities throughout the day and also taught me how to take time out to take care of my body mentally, emotionally, and physically. I don’t always have to do things alone. I should get support from friends, family, and the community. I had an excellent teacher, very informative and friendly. I am very happy that I attended the sessions. I am looking forward to attending another class. my goal is to continue being active. thank you so very much. I like the program however life goal in my way (60 year-old, non-Hispanic Black).

DISCUSSION

Physical activity improves cancer survivors’ health outcomes and HRQOL, but the feasibility and effectiveness of physical activity programs for survivors with MBC has been inconsistent in previous studies. The ALAC program was offered to improve physical functioning and quality of life in cancer survivors through increased physical activity. This study examined the effects of the ALAC community physical activity program on the improvement of HRQOL and physical function as well as physical activity, program retention and satisfaction among racial and ethnic minority and medically underserved MBC survivors compared to early-stage breast cancer survivors. We observed significant increases in minutes of MVPA and improvements of physical function and HRQOL in survivors with both early-stage breast cancer and MBC after the 12-week ALAC physical activity program.

Results of studies of home-based exercise interventions for survivors with MBC have been mixed. Two studies showed increased physical activity and improved physical function and mental health [27] and reduced fatigue [28], but another study found no significant improvement of self-reported physical function for patients with MBC [16]. Even when previous studies showed significant improvements in physical function and HRQOL, they also reported a high attrition rate (45%) [29] and poor adherence for unsupervised aerobic exercise among MBC survivors [17, 18]. Several recent studies also examined the effectiveness and feasibility of structured exercise programs for patients with MBC. A 12-week exercise program consisting of 1-hour bi-weekly group exercises increased the number of repetitions in a sit-to-stand test and decreased fatigue [30], a tailored exercise program improved self-reported HRQOL [15], and a home-based adapted physical activity program had a positive effect on cardiorespiratory fitness and physical function [31]. These intervention programs were determined to be feasible. In our study, women with MBC completed the ALAC program with a similar rate of session attendance as early-stage breast cancer survivors and had significant improvements of physical function and HRQOL. Therefore, while challenges such as adherence and mixed results from previous studies exist, recent evidence suggests that home-based physical activity interventions hold promise in improving physical function, reducing fatigue, and enhancing quality of life for survivors with metastatic breast cancer. After the ALAC program survivors in both groups increased their minutes of MVPA, and we observed an increase in both groups in the percentage of survivors who met the recommendation of 150 min/wk of moderate to vigorous aerobic activity to levels that exceed those of a national sample of US cancer survivors [32]. The percent who met the recommendation in early-stage and MBC was 32% and 39% at baseline, and 66% and 50% after program, respectively. Physical function, measured using 30-sec sit-to-stand test, was improved after the program. The percent who above the 50^th percentile of sit-to-stand for age and gender in early-stage and MBC were 55% to 38% at baseline and 76% and 77% at follow-up, respectively. Health-related quality of life (HRQOL) also improved after the intervention, as the T-scores were increased in both groups. However, their T-scores are still between 40 to 50 after the program, which means their HRQOL is still one standard deviation below the population mean.

To gauge feasibility of the ALAC program, we assessed program satisfaction and found that about 99% of participants were satisfied with the ALAC program overall. Although women with MBC had slightly lower program satisfaction compared to women with early-stage breast cancer (early stage, 99% vs. metastatic, 96%), the difference was not statistically significant, which indicates both groups were highly satisfied with the ALAC program. In addition, survivors with MBC reported that program instructors and peer survivors helped keep them active, healthy, motivated, and emotionally positive in this study. The social support offered by group-based programs such as this one may be helpful for survivors with MBC to share their experiences with others and increase motivation for participating in and adhering to the exercise program. Often survivors with advanced cancer are excluded from this type of community physical activity program. However, we found that survivors with MBC were able to participate in the program alongside survivors with early-stage disease and benefit from it. In addition, previous physical activity programs have had feasibility (adherence) and safety issues and increased fatigue among MBC survivors, but the results of this analysis confirm the ALAC program’s is feasibility and effectiveness, and survivors with metastatic cancer report high program satisfaction. This is possibly due in part to the flexible nature of the physical activity recommendations of the program, which encourage participants to be active at a level that is appropriate for their physical condition. These findings highlight the significance of integrating physical activity interventions, such as ALAC program, into the comprehensive care of cancer survivors, including survivors with metastatic disease. Survivors with metastatic cancer represent a fairly small proportion of the overall participants in the Active Living After Cancer program. It is possible that the recruitment methods used, which rely in part on community event recruitment, may not represent the best ways to reach out to cancer survivors with metastatic disease. It could also be that only the healthiest survivors with metastatic disease enroll in the program. Because the participants represent a volunteer sample rather than being selected from a defined population it is not possible to evaluate this directly, but it seems likely. If this is the case this would limit the generalizability of the results to the group of metastatic breast cancer survivors who are relatively healthy.

To our knowledge, this is the first study examining the effectiveness and feasibility of a physical activity program among survivors with MBC compared to those with early-stage breast cancer participating in the same program. As expected, we found that women with MBC had significantly lower baseline physical function and physical health domain scores of HRQOL compared to women with early-stage breast cancer. With these comparisons, we aimed to explore the potential difficulties in engaging women with MBC in an exercise program and how such a program could be effective and feasible for them. After the program, we found no significant group differences in changes in outcomes, indicating that the ALAC community-based physical activity intervention was feasible and effective in improving physical function and HRQOL for both survivors with early-stage breast cancer and those with MBC. Program satisfaction further suggests that a community/home-based physical activity program can be helpful in improving physical function and HRQOL among survivors with metastatic diseases, providing social support from other survivors and reducing the burden of engaging in structured and supervised exercise programs.

However, this study has some limitations. Firstly, our study sample was geographically limited, as participants were recruited only from Texas, making it difficult to generalize our findings to cancer survivors in other areas. Secondly, the stage of cancer was self-reported, potentially leading to errors in the classification of early-stage versus metastatic breast cancers. Thirdly, self-reported physical activity was assessed using different measures, namely the IPAQ and the Godin Leisure-Time Physical Activity Questionnaire, at different phases of the study. Over the course of the project, we found that the IPAQ was difficult for participants to complete, and that they often seemed to over-report their physical activity. We switched to the Godin Leisure-time Physical Activity Questionnaire, as it has been used extensively in research with cancer survivors [33], and has good test-retest reliability (.81 for total score) [34]. Finally, the physical activity levels at baseline in our study sample may indicate that a healthier segment of the cancer survivor population enrolled in the program, which would limit the generalizability of the results. However, the below average scores on the sit to stand test and the health-related quality of life scales indicate that this may not be the case, so it is possible that the high levels of physical activity were over-reported.

Despite these limitations, the study has strengths, including the inclusion of women with metastatic diseases who have been excluded from many other exercise and physical activity programs for cancer survivors. We were able to compare satisfaction and outcomes for breast cancer survivors with metastatic disease to those with early disease participating in the same program, which has not been previously reported in the literature. Moreover, this study provided an evidence-based lifestyle physical activity program for diverse and medically underserved survivors, contributing to efforts to overcome health disparities in cancer research.

The findings of this study suggest that the ALAC community physical activity program can effectively improve physical function and HRQOL among both early-stage breast cancer survivors and those with MBC who enroll in the program. The study also highlights the importance of social support and peer interaction in enhancing program satisfaction and adherence, particularly for survivors with MBC. Further research in this area could contribute to the development of tailored exercise/physical activity interventions that cater to the unique needs of metastatic breast cancer survivors, ultimately improving their overall well-being and quality of life.

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.