Abstract
Purpose:
Physical activity has been shown to decline over the course of chemotherapy in breast cancer survivors; yet it may reduce treatment-related side effects and emerging evidence indicates it may improve disease outcomes. Mobile health (mHealth) interventions may be an effective, scalable strategy to increase physical activity during treatment. However, little is known about breast cancer patients’ interests and preferences for these interventions. It is important to understand patients’ interests and preferences prior to development of mHealth physical activity interventions to increase their relevance and efficacy.
Methods:
Breast cancer survivors (n=30) participated in a semi-structured phone interview and asked about barriers and facilitators to physical activity during chemotherapy as well as their preferences on a range of potential mHealth intervention features. Transcribed interviews were coded and key themes were analyzed using an iterative, inductive approach.
Results:
Five key themes were extracted from the interviews: 1) Need for education about physical activity during chemotherapy; 2) Treatment side effects inhibit physical activity; 3) A structured, home-based, tech-supported program with in-person elements is most feasible; 4) Need for a personalized, highly tailored intervention; and 5) Importance of social support from other breast cancer survivors, friends, and family.
Conclusions:
Breast cancer survivors are interested in mHealth physical activity interventions during chemotherapy but preferences for intervention content and delivery varied. Future work should engage patients and survivors in intervention development and testing.
Keywords: physical activity, breast cancer patients, breast cancer survivors, chemotherapy, mHealth
INTRODUCTION
There will be approximately 266,120 new cases of breast cancer in the United States in 2018 [1]. The National Institutes of Health currently recommends adjuvant chemotherapy for most breast cancer patients following surgery to improve disease-free and overall survival [2-4]. There are a range of physical (i.e. nausea, vomiting, diarrhea, neuropathy, weight gain, pain), psychological (i.e. depression, anxiety, fatigue), and functional (i.e. cognitive impairment) chemotherapy side effects [5] which may increase chronic disease and second cancer risk and compromise quality of life [6]. Physical activity is both safe and beneficial during cancer treatment [7] and can lessen many of the common chemotherapy side effects [8-10]. It is recommended that women undergoing cancer treatment, including chemotherapy, should engage in at least 150 minutes of moderate to vigorous intensity physical activity (MVPA) per week [7, 11, 12]. However, physical activity levels tend to decline during chemotherapy treatment and often do not return to baseline or continue to decline following treatment completion, while sedentary time remains high and constant [13-16]. Because cancer diagnosis is a life-changing, emotional event which inspires many survivors to focus on their health, including behaviors such as exercise, the treatment period has been identified a potential teachable moment, where survivors may be receptive to support in changing their health-related behaviors [17]. However, physical activity promotion is not currently the standard of care for breast cancer survivors, and few programs exist to facilitate physical activity participation for women undergoing treatment.
Professionally-led, supervised, on-site programs may be ideal for women undergoing chemotherapy due to their more robust effects on health outcomes including fatigue, quality of life, fitness and muscular strength [18]. However, the need for on-site appointments, travel and limited time slot availability limit widespread access for survivors [19, 20]. Furthermore, “static” interventions with set activity schedules often ignore that symptom burden and barriers to physical activity in women undergoing chemotherapy may vary within a day or from day to day and are dynamic in terms of frequency and severity as a result of chemotherapy treatment’s cyclical nature [5]. Effective interventions that are less burdensome, require fewer resources and can be adapated to meet individual needs and capabilities are needed for women undergoing treatment.
Mobile health (mHealth) physical activity promotion interventions have the potential to address many of these needs and have demonstrated efficacy in increasing activity in other populations, including the general public and those reported to have low baseline MVPA levels [21,22]. These interventions are convenient for patients because they can be delivered remotely using technology (i.e. smartphones) many already own, are relatively low cost and less resource intensive and can be tailored to individuals in real time. Studies among post-treatment breast cancer survivors have demonstrated they are interested in technology-supported interventions and wearable devices (i.e. Fitbits, Jawbones) [23,24]. Studies of cancer survivors with mixed disease types indicate interest in smartphone applications (apps) that provide positive, concise, and tailored recommendations with built-in tools such as progress tracking, goal-setting, and motivational reminders [25] that incorporate more information related to their experience as a cancer survivor than commercially available smartphone apps [26]. Additionally, evidence indicates preferences of post-treatment breast cancer survivors differ from other survivor groups [27]. However, findings from post-treatment survivors may not generalize to breast cancer survivors undergoing chemotherapy due to the acute physical, emotional and psychological side effects of chemotherapy and the burden of the additional medical appointments during chemotherapy. Thus, understanding the specific needs of breast cancer survivors undergoing chemotherapy will be critical for the successful design of mHealth physical activity interventions in this populations.
The purpose of this study was to examine, through semi-structured interviews with breast cancer survivors who recently completed chemotherapy, survivors’ needs and preferences for mHealth physical activity interventions during chemotherapy. This qualitative approach allows for the consideration of complex factors that may influence breast cancer survivors’ physical activity and their preferences for a physical activity intervention during chemotherapy.
METHODS
Study Design
This was a cross-sectional, qualitative study using one-on-one, semi-structured phone interviews with women who had received breast cancer treatment at a large, Midwestern academic medical center. One-on-one interviews were chosen to provide participants with a comfortable environment in which to share their candid thoughts regarding potentially sensitive and personal experiences during chemotherapy without any potential contamination from others’ viewpoints, social pressures or concern about judgment from others. All methods were approved by the Institutional Review Board, and consent was obtained from all participants prior to collecting data.
Recruitment
Women who recently completed chemotherapy for breast cancer were recruited from a convenience sample of women who had participated in a previous study examining physical activity during chemotherapy and had agreed to be contacted regarding future studies. Inclusion criteria were: female; ≥18 years of age; diagnosed with stage I-III breast cancer; within 18 months of chemotherapy; owned a smartphone; and had access to the Internet. We did not restrict based on current physical activity or physical activity during chemotherapy as we thought it was important to capture the views of women who were successful at being active as well as those who were not. Survivors who met these criteria based on their responses to a web-based screening questionnaire were automatically directed to an online informed consent.
Data Collection
Demographic information and disease characteristics were collected via an online questionnaire immediately following informed consent. Consented participants were contacted via email to schedule a time for a phone interview with a study team member and were emailed a reminder a day in advance. Participants received up to three reminders to complete the questionnaires and schedule a phone interview. Survivors participated in semi-structured interviews lasting approximately 30-45 minutes over the phone and were asked questions regarding their preferences for physical activity during chemotherapy, whether they thought technology would be useful during chemotherapy, and how they would prefer to receive support (see Table 1). Participants received a personalized thank-you email after interview completion and were paid $15.00.
Table 1.
Interview Guide Questions
| Target | Question |
|---|---|
| PA History | What is your current physical activity routine? What did it look like PRIOR to cancer? |
| Facilitators/ Barriers to PA | What were the biggest barriers to physical activity during chemotherapy for you and other survivors? What would help physical activity during chemotherapy for you and other survivors? |
| PA During Chemotherapy | Would you have been willing to participate in a physical activity intervention DURING chemotherapy treatment? Why or why not? If yes, what would you have liked this program to look like? If there were a technology-supported physical activity intervention available during chemotherapy, what features would you like to see included? |
| Day-of Infusion PA | Would you have been willing to: 1) perform physical activity and/or b) meet with a physical activity coach before, during or after chemotherapy infusions? Why or why not? |
Measures
Demographic and Disease Characteristics.
Survivors self-reported demographic information including age, race/ethnicity, income, education, employment status, height and body weight to calculate body mass index, and overall health status. They also reported disease stage, menopausal status at diagnosis, date of last chemotherapy treatment, disease stage and treatment, overall health status and whether they had ever been diagnosed (yes/no) with a list of twenty chronic conditions (i.e. diabetes, hyperlipidemia, hypertension). Finally, participants also reported on whether their oncologist had recommended MVPA during chemotherapy (yes/no).
Physical Activity.
To obtain an estimate of MVPA participation during chemotherapy, participants were also asked to indicate (yes/no) whether they engaged in any MVPA during chemotherapy. If they indicated yes, they were asked to indicate the number of times per week and the average time per session. These values were multiplied to estimate the weekly time spent in MVPA during chemotherapy.
Current MVPA participation was measured using the Godin Leisme Time Exercise Questionnaire [28], which has demonstrated sufficient reliability in cancer populations [29]. Participants reported the frequency and average amount of time spent engaging in vigorous, moderate, and light intensity exercise over the previous seven days. Reported time spent in moderate and vigorous activity was multiplied by the respective number of reported times per week in each respective activity. These two values were summed to calculate the weekly time spent in MVPA.
Phone Interviews.
The research team developed a semi-structured interview guide which was followed during the interviews (see Table 1). Interviews were completed over the phone by a trained study team member (AMN). Interviews were recorded with participants’ consent, transcribed by a professional transcriber who was not part of the study team, and de-identified.
Data Analyses
Demographic data were analyzed using descriptive statistics. For interview data, key themes were identified through thematic text analysis using an inductive, data-driven approach [30, 31]. Two research team members (AMN and AMC) independently read through interview transcripts to identify key concepts found in several participants’ responses and iteratively developed a code book (i.e. code names and meanings) which was reviewed by the larger research team until consensus was reached. Two of three study team members (AMN, AMC, EAT) independently read each transcript and assigned codes to relevant content. Discrepancies in coding were resolved through discussion with the larger research team. The larger team met to organize codes into broader thematic categories based on conceptual similarities and a priori research questions. Consensus on the five thematic categories was reached through discussion. Two team members (from among AMN, AMC, EAT, KLG, SMP, WAW) were assigned to independently review the narrative content within each specific thematic category, summarize findings and identify illustrative quotes. Each pair reviewed any inconsistencies, and discrepancies were resolved through iterative consensus with the larger research team, who reviewed summaries of all thematic categories in order to determine key overarching themes [33]. Dedoose software [32] was used to organize narrative content within thematic categories.
RESULTS
Participants
Of the 72 breast cancer survivors invited to participate in the study, 34 women consented to participate. Of these, 31 completed the interview. However, the recorder malfunctioned for one interview so all analyses are based on the 30 individuals who completed the interview and had a recording. Sample demographic and disease characteristics are displayed in Table 2. Briefly, women were on average 45.5 years of age (SD=9.6 years). The majority (80%) were white, and 13.3% identified as Hispanic or Latina. Most women had completed at least a college education (86.6%) and about two-thirds (66.7%) reported an annual household income of >$100,000. On average, participants were 5.7 months (SD=3.8 months) since chemotherapy completion and the vast majority (93%) reported their health status as “good” or better. Approximately two-thirds of the sample reported early stage (I or II) disease while just over half reported having received radiation therapy (59.3%). Only 10% of women were currently receiving radiation therapy while 53.3% reported they were currently taking endocrine or hormonal therapy medications for their cancer. Finally, 83.3% of participants reported their oncologist had recommended physical activity during chemotherapy.
Table 2.
Sample Demographic and Disease Characteristics
| Factor | Interview Sample (n=30) |
|---|---|
| Age (M, SD) | 45.5 (9.6) |
| Race | |
| White (%) | 80.0 |
| Black (%) | 13.3 |
| Asian (%) | 3.3 |
| Other (%) | 3.3 |
| Hispanic or Latino (%) | 13.3 |
| Education | |
| At least College Degree (%) | 86.6 |
| Less than College Degree (%) | 13.3 |
| Employment Status | |
| Working at least part-time (%) | 93.3 |
| Not working (%) | 6.7 |
| Annual Household Income | |
| > $100,000 (%) | 66.7 |
| ≤ $100,000 (%) | 16.6 |
| Prefer not to answer | 16.7 |
| Overall Health Status | |
| Fair (%) | 6.7 |
| Good/Very Good (%) | 80.0 |
| Excellent (%) | 13.3 |
| Body Mass Index (M, SD) | 27.5 (8.5) |
| Number of Comorbid Chronic Conditions (M, SD) | 1.2 (1.6) |
| Menopausal Status at Time of Diagnosis | |
| Pre-menopausal (%) | 60.0 |
| Post-menopausal (%) | 30.0 |
| Not sure (%) | 10.0 |
| Disease Stage | |
| Stage I (%) | 24.1 |
| Stage II (%) | 44.8 |
| Stage III (%) | 31.0 |
| Treatment | |
| Months since Completed Chemotherapy (M, SD) | 5.7 (3.8) |
| Previously Received Radiation Therapy (%) | 59.3 |
| Currently Receiving Radiation Therapy (%) | 10.0 |
| Taking Endocrine or Hormone Therapy Medication(s) (%) | 53.3 |
| Oncologist Recommended Exercise during Chemotherapy (%) | 83.3 |
| Physical Activity | |
| During Chemotherapy | |
| Report Any MVPA during Chemotherapy (%) | 66.7 |
| Weekly Minutes of MVPA during Chemotherapy (M, SD)* | 102.4 (158.8) |
| Meeting MVPA Recommendations during Chemotherapy (%) | 23.3 |
| Current | |
| Current Minutes of Weekly MVPA (M, SD) | 157.3 (195.8) |
| Currently Meeting MVPA Recommendations (%) | 36.7 |
Physical Activity
Two-thirds (66.7%) of participants indicated they participated in any MVPA during chemotherapy. On average, women reported engaging in 102.4 (158.8) minutes of MVPA each week during treatment. Only 23.3% of the sample reported meeting public health recommendations of 150 minutes of MVPA per week [7] during chemotherapy. At the time of interview (average of 5.7 months post-chemotherapy), participants reported engaging in an average of 157.3 (SD=195.8) minutes of MVPA each week and 36.7% of the sample reported meeting recommendations.
Interviews
After coding interview content, five main themes emerged. These five themes are described in detail below. Table 3 includes quotations pertaining to each theme.
Table 3.
Relevant Quotations for each Theme
| Theme | Key Quotations |
|---|---|
| Need for education about PA during chemotherapy | “I think if I had specific information about the finding and what the associations were and the benefits, then I think I would have really integrated it much more, and considered it more part of my medical planning.” –Participant 500 |
| “While I was taking chemo was always looking up stuff, ‘cause I wanted to know everything about side effects. I wanted to know about eating habits. I literally just scoured the internet for everything. Virtually every day I was looking up something that was related to my breast cancer diagnosis, so to include some type of informative articles, that would be great too, ‘cause the one thing about looking up stuff online is you don’t always have current information” –Participant 510 | |
| Treatment side effects inhibit PA | “Physically, I think the few days after you receive the chemo treatment, I was just really knocked out, I was really tired, I was really motivated to get through my work day and get home and go to sleep.” –Participant 520 “Something that I went through with chemo that I had not ever dealt with before was the menopausal-type symptoms. Hot flashes, sweating, you know my hair fell out too, so I had to deal with feeling uncomfortable that way. Working out during those hot flashes might have been more uncomfortable.” –Participant 530 |
| “So many people are having surgery around, before chemo, after chemo. For me, that was the biggest set back.” –Participant 540 | |
| A structured, home-based, tech-supported program with in-person elements is most feasible | “As for in-person exercise sessions, when I was having a chemo treatment every three weeks I probably wouldn’t have left the house for the first 10 days. Doing something at home would have been more likely.” –Participant 610 |
| “In that infusion suite would be an ideal time for somebody to come in and talk through the plan that you have. What are you going to do during this three week round? Kind of set you up for hopefully, some success until the next time you’re in that room. Not only does it break up the monotony of sitting there, but it’s a good time to make use of.” –Participant 620 | |
| “I like the idea of reporting how you’re feeling and then getting a motivational text back. So if those texts said, ‘Have you reached 5,000 steps today?’, or ‘Have you walked for 15 minutes?’ Tasks might be more motivating to me than just a phrase that says something like, ‘Walking can help you feel better.’ I think I’m more goal oriented. I need a task.” –Participant 630 | |
| Need for a personalized, highly tailored intervention | “The program needs to take into account the side effects and how women are reacting and what could they do to continue to encourage them despite going through these side effects. Toward the end of your treatment, the side effects are going to be harder. Recognize if there are days they need to not be active or days they need to rest instead.” –Participant 550 |
| “In a really perfect, wonderful world, we’d each get like at the outset of treatment, somebody who tailor a plan to our specific situation. Taking into account our current state of fitness and health, outside of the diagnosis of breast cancer. And creating a plan to move that would not only help you get through the breast cancer treatment and survivorship, but also, keep you on a path of fitness regardless of where you’re starting. Then touch base through treatment. Tweak that plan based on how treatment is going and how we’re adapting” –Participant 560 | |
| “On the online videos, if they were catered to me, to say here’s a short list of things you could do, which is specific to your profile and what you tend to enjoy and the kind of treatment you’re going through and if you just had surgery, and all that kind of stuff. Again more customized.” –Participant 570 | |
| Importance of social support from other breast cancer survivors, friends, and family | “Another positive would be if online there could be a community of breast cancer patients receiving treatments that share their experiences on workouts, like, ‘Okay, this is what’s working for me, this doesn’t work for me, this makes me feel better, this doesn’t make me feel better.’” –Participant 580 |
| “The women that aren’t as physically active will need extra encouragement. If they could talk to women, or have access to women who stayed physically active through chemo, so they could hear for themselves how it could help them, I think that could also be very helpful.” –Participant 590 | |
| “Maybe one meeting in person at the beginning and then you do some online stuff. So, not very many in person meetings, but at least once. Because I feel like something when you just go online it’s hard to get people.” –Participant 600 | |
| “Get your family and your friends involved in it. If that person’s hearing the same story, that’s a really good reinforcer. With my husband, if he, for instance, had said, ‘Hey, you haven’t gotten up. Let’s get up and go for a walk.’ Even that would make me more motivated to be more physically active.” –Participant 570 |
Theme 1: Need for Education about Physical Activity during Chemotherapy
Many survivors agreed that they knew about the exercise benefits for the general population, but wanted more specific information about the safety and benefits of exercise during chemotherapy. Confusion about these topics on the part of both survivors and family members, in addition to a perceived relative lack of guidance from their oncologist, was cited as a common reason for not engaging in physical activity during chemotherapy. Many survivors were concerned about how to establish an exercise routine that avoids exposing them to pathogens, overheating, and over-exertion. They believed specific information on how physical activity may help manage or reduce side effects and how to perform activity safely would be helpful and motivational. Finally, many breast cancer survivors mentioned wanting their family and caregivers to be included in receiving education on these topics to mitigate their concerns and provide additional support.
Theme 2: Treatment Side Effects Inhibit Physical Activity
Chemotherapy side effects influenced many areas of survivors’ lives, including their self-efficacy for exercise and interest in certain exercise program features. The most frequently cited chemotherapy side effects included fatigue, pain, overheating, and hair loss. The experience of treatment-related side effects also including nausea, depression, anxiety varied amongst patients as well as within and between treatment cycles. Fatigue often lead survivors to feel as if they had a limited “energy reserve” to pull from throughout the day, and that energy would be preferentially allocated to work or family above physical activity. This was a major barrier to physical activity which most women agreed must be taken into account to design a realistic, feasible intervention. Physical side effects, such as hair loss, made the survivors self-conscious about exercising in public because they did not want pity from others for being a cancer patient. Wigs were uncomfortable and lead to overheating. In addition, survivors were unsure whether they would be physically capable of exercise and were anxious about exercising in many environments due to perceptions of increased risk of harm (e.g. overheating outdoors in the summer, contracting infections in public gyms). Survivors were interested in an exercise program that would provide appropriate activity recommendations taking into account these side effects.
Theme 3: A Structured, Home-Based, Tech-Supported Program with In-Person Elements is Most Feasible
Overall, breast cancer survivors indicated a “hybrid” physical activity program incorporating some in-person element(s) alongside technology components would be most useful to women undergoing chemotherapy. Survivors thought some in-person (group or individual) element was important and emphasized the need for this to be convenient. Almost all women endorsed the idea of having in-person sessions on treatment days, before or during infusions, because it would be convenient and they could participate before treatment side effects set in. However, many expressed the need to tailor timing to the specific type of treatment because some medications taken prior to infusions made them groggy. Additional concerns included requiring caregivers to get them to the cancer center early, the travel time required to get to treatment facilities, and wires getting caught in exercise equipment. Generally, most survivors felt an exercise coach would be the most feasible in-person option and wanted this person to be highly trained in exercise and breast cancer treatment so they could provide accountability, encouragement and advice on setting goals, creating a workout plan, and overcoming barriers.
Many survivors believed combining in-person coaching sessions with technology features would provide them with much needed additional help to become or stay active in between coaching sessions. They emphasized the need for technology to be easy to use, personalized, and encouraging. In particular, they liked the idea of reminder and congratulatory text messages when they reached their goals, but indicated these messages needed to be positive, not pushy, and recognize the challenges faced during treatment. Survivors were also enthusiastic about a smartphone application designed specifically for women undergoing chemotherapy that would help them self-monitor their activity so they could easily create goals and see their progress. Survivors also thought a wearable activity tracker (i.e. Fitbit, Jawbone) would be very useful, easy to use, and could be incorporated with an app to encourage self-monitoring and provide feedback on progress.
Theme 4: Need for a Personalized, Highly Tailored Intervention
The majority of survivors were interested in a highly tailored, adaptive, and personalized physical activity intervention. Survivors were interested in tailoring based on physical activity levels prior to diagnosis, treatment characteristics (i.e. the type of chemotherapy, treatment cycle, and days since last treatment cycle), symptom burden, daily schedule, and the weather. They wanted their physical activity prescription to be specific to breast cancer patients undergoing treatments and their potential side effects and include choices of activities, a specific option to engage in a lower dose of physical activity when necessary, and detailed instructions of how to complete them. Survivors expressed interest in having these personalized interventions delivered via exercise videos or text messages. Survivors were also interested in the ability to have flexible and personalized levels of contact with the study team such that the mode of contact (i.e. call, text message, email) and frequency would be tailored to personal factors including their preferences, symptoms, treatment characteristics, and physical activity history.
Theme 5: Importance of Social Support from other Breast Cancer Survivors, Friends, and Family
Survivors were generally interested in some level of social support from other survivors going through treatment or those who had successfully finished treatment. They wanted at least some of this social interaction to be supported via technology through messaging boards or chatting features in an app. Many women mentioned wanting to meet other survivors in-person to introduce themselves before interacting online and suggested a one-time introductory meeting, although their interest in meeting in-person to exercise was mixed. Some thought the extra accountability would be helpful, while others felt it might prompt self-consciousness if ability levels in the group varied and that regularly finding a meeting location convenient for everyone would be a challenge.
Survivors also had varied opinions about how individuals from their personal life (i.e. family and friends) should be included. For many, family and friends were viewed as a barrier to physical activity as they often encouraged survivors to rest and be less active due to concerns about safety and risk of infection. Survivors indicated providing family and friends with education about the safety and efficacy of physical activity during chemotherapy could help them provide more effective support. Finally, survivors reported that they would have appreciated monitoring or support for their physical activity from their doctors but recognized their time constraints.
DISCUSSION
Five themes for desired mHealth physical activity intervention features during chemotherapy for breast cancer were identified via our interviews with survivors: 1) Need for education about physical activity during chemotherapy; 2) Treatment side effects inhibit physical activity; 3) A structured, home-based, tech-supported program with in-person elements is most feasible; 4) Need for a personalized, highly tailored intervention; and 5) Importance of social support from other breast cancer survivors, friends, and family. Overall, survivors thought a mHealth intervention with elements such as a wearable activity tracker, smartphone application, motivational text messages, and social networking combined with in-person elements would be the most beneficial. Key aspects desired by survivors included thorough educational information for survivors and families, social support from other survivors, and tailoring to their specific daily symptoms, schedule, and point in treatment. While 83.3% of survivors reported that their oncologists recommended exercise during treatment, participants indicated a perceived lack of guidance on physical activity from their provider indicating the quality or guidance around this recommendation may not be sufficient.
Our finding that survivors are interested in highly tailored interventions that integrate wearables with a smartphone app is consistent with findings in post-treatment survivors [23-26] and the American College of Sports Medicine recommendation that survivors’ exercise prescriptions be tailored to individual factors (i.e. pretreatment fitness, comorbidities, type of and response to treatment) [7]. While studies in post-treatment survivors show differences in the sedentary time and MVPA based on age, education, number of children, family history of breast cancer, and levels of pre-diagnosis MVPA [34], our study indicates additional tailoring variables (i.e. fatigue, treatment timing) may need to be considered in interventions for women undergoing chemotherapy to enhance intervention efficacy. Additionally, our data indicate using wearable data to further tailor the intervention by regularly revising survivors’ goals and sending motivational text messages may be acceptable ways to tailor interventions during treatment. However, future work is warranted to further explore appropriate and effective tailoring variables and methods in this population who are already burdened by treatment visits and side effects to ensure the intervention is appropriate and not overly burdensome. Survivors in our study also emphasized the importance of social support in becoming or staying physically active, consistent with other studies [26]. Future work is needed to understand the most effective ways (i.e. discussion boards, webinars, etc.) to provide peer support in the context of technology-support physical activity promotion interventions during treatment. The variability in participants’ interests in different intervention features suggests there may not be a “one-size-fits all” MVPA promotion intervention for women undergoing chemotherapy for breast cancer. Future work should consider systematically and rigorously testing different intervention components and tailoring decision rules simultaneously using the Multiphase Optimization Strategy framework (MOST; [35, 36]) including factorial experiments to test different components or component levels. Sequential Multiple Assignment Trials (SMART; [35]) to examine intervention component sequence or Micro-randomized trials [37] to examine appropriate ways to tailor text messages and other intervention features. These rigorous trial designs allow for rapid studies to identify and adapt the most effective technology-supported physical activity promotion intervention components, component levels or component sequence(s) to better understand what works for whom, in what contexts, and for what outcomes to optimize MVPA interventions for specific subgroups, contexts or outcomes [38].
While many of the findings from this study are consistent with those from post-treatment survivors, there are several differences between the desired features for mHealth physical activity interventions during chemotherapy identified in this study and those identified for the post-treatment period. This study gives insight to a number of barriers and adaptations to consider that are unique to the treatment period. First, survivors in our study reported a need for encouragement to do any form of activity during the period of chemotherapy treatment. This may reflect differences in goals for women undergoing treatment (i.e. to maintain functioning or prevent drastic declines) versus those post-treatment (i.e. to meet or exceed pre-cancer physical activity levels or lose weight) [24]. While survivors undergoing treatment and those who have completed it both desire a program tailored to their unique needs and side effects, survivors receiving chemotherapy may need additional support in dealing with the general treatment experience, including acute side effects (i.e. fatigue and nausea). Additionally, because of the high risk of medical complications in those undergoing chemotherapy, any mHealth physical activity intervention will likely require regular contact with the study team which may not be necessary in low-risk, post-treatment survivors. Our findings provide preliminary information regarding survivors’ preferences for the amount and mode of contact with the study team but also emphasize the need for a program to be as convenient as possible and accessible to outside of the hospital setting. Future work should explore how to best address these needs. Lastly, breast cancer survivors actively undergoing treatment experience higher levels of depression and anxiety, cited as a major barrier to engaging in activity, than post-treatment survivors [39]. It is important to consider how the mental health and symptom burden of cancer survivors undergoing chemotherapy may factor into their motivation to exercise and participate in a physical activity intervention and determine whether both issues should be addresses simultaneously or sequentially.
There are several limitations of the current study that should be addressed in future work. One coder of transcripts was the original interviewer, which could introduce some bias in the findings. However, all interviews were double-coded to reduce bias. Someone presently undergoing chemotherapy may respond differently than the survivors interviewed, who were on average 5.7 months (SD= 3.8 months) from their last dose of chemotherapy. Future work should try to capture women’s needs while they are undergoing chemotherapy. While 23.3% of our sample met MVPA guidelines during treatment, the inclusion of these women was important in order to learn how to encourage and prevent declines in other women’s physical activity. We also only included the survivor perspective. Engaging cancer healthcare team members could enhance the uptake and impact of mHealth physical activity promotion interventions during chemotherapy. Furthermore, our sample was fairly homogenous in terms of race, ethnicity, education, and income (see Table 2). All participants in our study received care at a National Cancer Institute designated comprehensive cancer center in an urban metropolitan area. Preferences should be explored in more diverse cancer survivor samples receiving other treatments and among rural survivors or those undergoing treatment at community cancer centers. Finally, this is a cross-sectional, qualitative study. It is important to corroborate these findings and gain further insight into the ranking of what features survivors would find the most useful and whether these preferences change across time or with more experience using specific features. This could be done by collecting additional qualitative and quantitative data from a larger sample size, having survivors test various features and ultimately, designing an intervention incorporating these features to determine their efficacy, feasibility, acceptability, and user engagement.
Despite these limitations, strengths of this study lie in its original, in depth look at survivors’ preferences for the development of mHealth physical activity interventions during chemotherapy for breast cancer. To our knowledge, it is the first study of its kind to explore preferences for these types of programs during treatment. The rich data were obtained with a rigorous, iterative approach and provide insight beyond those that could be obtained quantitatively.
This study provides the initial step needed to inform the development of mHealth physical activity interventions for women receiving chemotherapy for breast cancer. Survivors were interested in a highly tailored intervention that would adapt to many factors including their preferences, treatment timing, symptom burden, and daily life. New technologies are making this increasingly possible, and research is warranted to further explore how to optimize and tailor interventions to these various factors. Future work should incorporate survivors’ perspectives as well as health care providers’ to develop and test highly-tailored mHealth physical activity interventions for not only women undergoing chemotherapy for breast cancer, but for other treatment modalities and cancer types to design more scalable, efficacious interventions to increases survivors’ activity and, ultimately, improve health and disease outcomes.
STATEMENT OF HUMAN RIGHTS.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Acknowledgements:
This research was supported by the Lynn Sage Cancer Research Foundation (Phillips), Northwestern University’s Summer Undergraduate Research Grant (Nielsen) and the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Dr. Welch Morelli and Dr. Gavin are supported on National Cancer Institute Training Grant award number T32CA193193 (PI Spring). Dr. Phillips is also supported by the National Cancer Institute (K07CA196840).
Footnotes
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to report. The authors have full control of all primary data and will allow the journal to review the data if requested.
REFERENCES
- 1.National Cancer Institute SEER Cancer Stat Facts: Female Breast Cancer. https://seer.cancer.gov/statfacts/html/breast.html. Accessed 2 August 2018
- 2.Wirtz P, Baumann FT (2018) Physical Activity, Exercise and Breast Cancer - What Is the Evidence for Rehabilitation, Aftercare, and Survival? A Review. Breast care (Basel) 13 (2):93–101. 10.1159/000488717 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Abrams JS (2001) Adjuvant therapy for breast cancer--results from the USA consensus conference. Breast cancer 8 (4):298–304 [DOI] [PubMed] [Google Scholar]
- 4.Mayo Clinic Staff (2017) Chemotherapy for Breast Cancer. Mayo Clinic; https://www.mayoclinic.org/tests-procedures/chemotherapy-for-breast-cancer/about/pac-20384931. Accessed 2 August 2018 [Google Scholar]
- 5.Partridge AH, Burstein HJ, Winer EP (2001) Side Effects of Chemotherapy and Combined Chemohormonal Therapy in Women With Early-Stage Breast Cancer. 2001 (30):135–142. 10.1093/oxfordjournals.jncimonographs.a003451 [DOI] [PubMed] [Google Scholar]
- 6.Curt GA, Breitbart W, Cella D, Groopman JE, Horning SJ, Itri LM, Johnson DH, Miaskowski C, Scherr SL, Portenoy RK, Vogelzang NJ (2000) Impact of cancer-related fatigue on the lives of patients: new findings from the Fatigue Coalition. Oncologist 5 (5):353–360 [DOI] [PubMed] [Google Scholar]
- 7.Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvao DA, Pinto BM, Irwin ML, Wolin KY, Segal RJ, Lucia A, Schneider CM, von Gruenigen VE, Schwartz AL (2010) American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc 42 (7):1409–1426. 10.1249/MSS.0b013e3181e0c112 [DOI] [PubMed] [Google Scholar]
- 8.Loprinzi PD, Cardinal BJ (2012) Effects of physical activity on common side effects of breast cancer treatment. Breast cancer 19 (1):4–10. 10.1007/s12282-011-0292-3 [DOI] [PubMed] [Google Scholar]
- 9.Reis AD, Pereira P, Diniz RR, de Castro Filha JGL, Dos Santos AM, Ramallo BT, Filho FAA, Navarro F, Garcia JBS (2018) Effect of exercise on pain and functional capacity in breast cancer patients. Health Qual Life Outcomes 16 (1):58 10.1186/s12955-018-0882-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.van Waart H, Stuiver MM, van Harten WH, Geleijn E, Kieffer JM, Buffart LM, de Maaker-Berkhof M, Boven E, Schrama J, Geenen MM, Meerum Terwogt JM, van Bochove A, Lustig V, van den Heiligenberg SM, Smorenburg CH, Hellendoorn-van Vreeswijk JA, Sonke GS, Aaronson NK (2015) Effect of Low-Intensity Physical Activity and Moderate- to High-Intensity Physical Exercise During Adjuvant Chemotherapy on Physical Fitness, Fatigue, and Chemotherapy Completion Rates: Results of the PACES Randomized Clinical Trial. J Clin Oncol 33 (17):1918–1927. 10.1200/jco.2014.59.1081 [DOI] [PubMed] [Google Scholar]
- 11.L. RC, Colleen D, Wendy DW, Jeffrey M, S. CK, L. SA, V. BE, K. HK, Barbara G, Marji M, Tim B, Ted G (2012) Nutrition and physical activity guidelines for cancer survivors. CA: A Cancer Journal for Clinicians 62 (4):242–274. 10.3322/caac.21142 [DOI] [Google Scholar]
- 12.The American Cancer Society medical and editorial content team (2014) Physical Activity and the Cancer Patient. American Cancer Society; https://www.cancer.org/treatment/survivorship-during-and-after-treatment/staying-active/physical-activity-and-the-cancer-patient.html. Accessed 26 July 2018 [Google Scholar]
- 13.Sabiston CM, Brunet J, Vallance JK, Meterissian S (2014) Prospective examination of objectively assessed physical activity and sedentary time after breast cancer treatment: sitting on the crest of the teachable moment. Cancer Epidemiol Biomarkers Prev 23 (7):1324–1330. 10.1158/1055-9965.Epi-13-1179 [DOI] [PubMed] [Google Scholar]
- 14.Huy C, Schmidt ME, Vrieling A, Chang-Claude J, Steindorf K (2012) Physical activity in a German breast cancer patient cohort: One-year trends and characteristics associated with change in activity level. Eur J Cancer 48 (3):297–304. 10.1016/j.ejca.2011.08.005 [DOI] [PubMed] [Google Scholar]
- 15.Irwin ML, Crumley D, McTiernan A, Bernstein L, Baumgartner R, Gilliland FD, Kriska A, Ballard-Barbash R (2003) Physical activity levels before and after a diagnosis of breast carcinoma: the Health, Eating, Activity, and Lifestyle (HEAL) study. Cancer 97 (7):1746–1757. 10.1002/cncr.11227 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Littman AJ, Tang MT, Rossing MA (2010) Longitudinal study of recreational physical activity in breast cancer survivors. J Cancer Surviv (2):119–127. 10.1007/s11764-009-0113-2 [DOI] [PubMed] [Google Scholar]
- 17.Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM (2005) Riding the Crest of the Teachable Moment: Promoting Long-Term Health After the Diagnosis of Cancer. J Clin Oncol 23 (24):5814–5830. 10.1200/jco.2005.01.230 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Sweegers MG, Altenburg TM, Chinapaw MJ, Kalter J, Verdonck-de Leeuw IM, Courneya KS, Newton RU, Aaronson NK, Jacobsen PB, Brug J, Buffart LM (2018) Which exercise prescriptions improve quality of life and physical function in patients with cancer during and following treatment? A systematic review and meta-analysis of randomised controlled trials. Br J Sports Med 52 (8):505–513. 10.1136/bjsports-2017-097891 [DOI] [PubMed] [Google Scholar]
- 19.Phillips SM, Alfano CM Perna FM & Glasgow RE (2014) Accelerating translation of physical activity and cancer survivorship research into practice: Recommendations for a more integrated and collaborative approach. Cancer Epidemiol Biomarkers Prev. 23(5):687–699. doi: 10.1158/1055-9965.EPI-13-1355. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Lopez C, Jones J, Alibhai SHM, Mina D Santa (2018). What is the “Home” in home-based exercise? The need to define independent exercise for cancer survivors. J Clin Oncol, 36 (9): 928–929. doi: 10.1200/jco.2017.76.4365 [DOI] [PubMed] [Google Scholar]
- 21.Coughlin SS, Whitehead M, Sheats JQ, Mastromonico J, Smith S (2016) A Review of Smartphone Applications for Promoting Physical Activity. Jacobs J Community Med 2 (1) [PMC free article] [PubMed] [Google Scholar]
- 22.Spring B, Pellegrini C, McFadden HG, Pfammatter AF, Stump TK, Siddique J, King AC, Hedeker D (2018) Multicomponent mHealth Intervention for Large, Sustained Change in Multiple Diet and Activity Risk Behaviors: The Make Better Choices 2 Randomized Controlled Trial. J Med Internet Res 20 (6):e10528 10.2196/10528 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Nguyen NH, Hadgraft NT, Moore MM, Rosenberg DE, Lynch C, Reeves MM, Lynch BM (2017) A qualitative evaluation of breast cancer survivors’ acceptance of and preferences for consumer wearable technology activity trackers. Support Care Cancer 25 (11):3375–3384. 10.1007/s00520-017-3756-y [DOI] [PubMed] [Google Scholar]
- 24.Phillips SM, Conroy DE, Keadle SK, Pellegrini CA, Lloyd GR, Penedo FJ, Spring B (2017) Breast cancer survivors’ preferences for technology-supported exercise interventions. Support Care Cancer 25 (10):3243–3252. 10.1007/s00520-017-3735-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Robertson MC, Tsai E, Lyons EJ, Srinivasan S, Swartz MC, Baum ML, Basen-Engquist KM (2017) Mobile Health Physical Activity Intervention Preferences in Cancer Survivors: A Qualitative Study. JMIR Mhealth Uhealth 5 (1). 10.2196/mhealth.6970 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Puszkiewicz P, Roberts AL, Smith L, Wardle J, Fisher A (2016) Assessment of Cancer Survivors’ Experiences of Using a Publicly Available Physical Activity Mobile Application. JMIR Cancer 2 (1):e7 10.2196/cancer.5380 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Forbes CC, Blanchard CM, Mummery W K, Courneya KS (2015) A Comparison of Physical Activity Preferences among Breast, Prostate, and Colorectal Cancer Survivors in Nova Scotia, Canada. Journal of Physical Activity and Health, 12(6), 823–833. doi: 10.1123/jpah.2014-0119 [DOI] [PubMed] [Google Scholar]
- 28.Godin G, Shephard RJ (1985) A simple method to assess exercise behavior in the community. Can J Appl Sport Sci 10 (3):141–146. [PubMed] [Google Scholar]
- 29.Amireault S, Godin G, Lacombe J, Sabiston CM (2015) The use of the Godin-Shephard Leisure-Time Physical Activity Questionnaire in oncology research: a systematic review. BMC Med Res Methodol 15:60 10.1186/s12874-015-0045-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Boyatzis RE. Transforming qualitative information: thematic analysis and code development. Thousand Oaks: Sage Publications; 1998. [Google Scholar]
- 31.Creswell JW. Qualitative inquiry and research design: choosing among five approaches. Thousand Oaks: Sage Publications; 2013. [Google Scholar]
- 32.Dedoose Version 8.0.42, web application for managing, analyzing, and presenting qualitative and mixed method research data (2018) Los Angeles, CA: SocioCultural Research Consultants, LLC; www.dedoose.com. [Google Scholar]
- 33.Glaser BG, Strauss AL (2009) The discovery of grounded theory: strategies for qualitative research. Transaction Publishers. [Google Scholar]
- 34.Boyle T, Vallance JK, Ransom EK, Lynch BM (2016) How sedentary and physically active are breast cancer survivors, and which population subgroups have higher or lower levels of these behaviors? Support Care Cancer 24 (5):2181–2190. 10.1007/s00520-015-3011-3 [DOI] [PubMed] [Google Scholar]
- 35.Collins LM, Murphy SA, Strecher V. The multiphase optimization strategy (MOST) and the sequential multiple assignment randomized trial (SMART): new methods for more potent eHealth interventions. Am J Prev Med 2007; 32: S112–S118. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Collins LM, Kugler KC, Gwadz MV. Optimization of multicomponent behavioral and biobehavioral interventions for the prevention and treatment of HIV/AIDS. AIDS and Behavior 2016; 20: 197–214. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Klasnja P, Hekler EB, Shiffman S et al. Microrandomized trials: An experimental design for developing just-in-time adaptive interventions. Health Psychol 2015;34:1220–1228. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.King AC, Ahn DF, Atienza AA, Kraemer HC. Exploring refinements in targeted behavioral medicine intervention to advance public health. Ann Behavl Med 2008; 35: 251–260. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A (2005) Depression and anxiety in women with early breast cancer: five year observational cohort study. BMJ 330 (7493):702 10.1136/bmj.38343.670868.D3 [DOI] [PMC free article] [PubMed] [Google Scholar]