Table 2.

Summary of papers included in the realist literature review.

First Author (Year), Country and Objective	Population, Setting and Intervention	Design and Methodological Rigour (Strong/Moderate/Weak)	Key Results	How the Intervention Was Thought to Work	Contextual Factors Thought to Influence Implementation
Danhauer et al. (2008). North Carolina, USA. Objective: To engage participants in a 10 -week yoga programme to improve symptoms and treatment-related side effects.	Population: Women with ovarian (stages I, II, III, IV) or breast cancer—2 to 24 months post-primary treatment (surgery) following the initial diagnosis and/or had a recurrence of ovarian or breast cancer within the past 24 months. Participants were recruited during and following chemotherapy or radiotherapy treatment. Mean age—58.9 years. Convenience sample. Women with ovarian cancer (n = 37) (all stages of disease). Women with breast cancer (n = 14). Participants were recruited from two local cancer centres. Setting: group classes delivered in a structured environment. Intervention: The intervention consisted of 10 weekly 75 min once-a-week yoga classes taught by a yoga instructor certified by the National Yoga Alliance who had cancer-specific yoga training; The 10 class sessions combined physical postures breathing and deep relaxation; No home yoga practice was required.	Pilot/feasibility intervention study. Rigour: moderate. Small feasibility study. Single group design with no control group.	Recruitment rate: 16%. Retention/adherence rate: 60%. FACT-G—p = 0.05. Physical health and fatigue—p = 0.05. Qualitative feedback—88% of the class indicated they enjoyed the classes.	Not in-person recruitment was not as effective as in-person recruitment. The support and example of peers in the group and or the instructor may enhance self-efficacy, thus increasing motivation to adhere to the intervention. Enjoyment of intervention leads to enhanced adherence. Improvement in physical symptoms as intervention progresses motivates women to engage in the intervention. Flexible individualised approach empowers women to engage in the intervention.	The relatively young age (mean—59 years) of participants when compared to the average of ovarian cancer population may have enabled engagement and increased adherence. The majority of participants (89%) had tertiary-level education; this may have resulted in increased awareness regarding the importance of exercise and increased adherence to the intervention. Implementation of intervention hindered by: Distance to the venue of exercise class; Too busy/schedule conflicts; Health issues; Rarely (n = 3) the effects of cancer treatment.
Hwang et al. (2016). Seoul, Korea. Objective: To investigate the effects of a comprehensive care program on cardiopulmonary function, muscle strength, immune response and quality of life in ovarian cancer survivors.	Population: Ovarian cancer survivors with stages I [14], II [8] and III [18]; Post-surgery and chemotherapy; Participants in remission for 6 months to 3 years prior to enrolment; Participants selected did not exercise more than 30 min three times per week prior to recruitment; Experimental group n = 20; Control group n = 20. Setting: group sessions in a clinical environment and the exercise intervention was home-based. Intervention: 8-week program; Group education—one 40-min session per week for eight weeks; Self-help home-based exercise—three 50-min sessions per week for eight weeks: Brisk walking—30 min; CD—demonstrating exercises; Participants kept an exercise log; Participants were contacted twice weekly by study personnel to discuss their exercise routine. Relaxation—three 15 min sessions per week; Relaxation therapy was performed at home after the exercise sessions.	Quasi-experimental non-equivalent control group design. Weak: non-equivalent group design; small study and sample size.	Recruitment rate: 92% (self-help group support) and 95% (home-based exercise group). Retention rate: 80% (both groups). Adherence rate: 95% (self-help group support) and 91% (home-based exercise group). Cardiopulmonary function was measured using 12 min walk distance test (p = 0.05). Muscle strength measured using a chair to stand test—30 in total (p = 0.01). FACT-G experimental group—p = 0.003, p = 0.004, p = 0.001, p = 0.002.	The support and example of peers in the group and or the instructor may enhance self-efficacy, thus increasing motivation to adhere to the intervention. The twice-weekly telephone calls may have motivated participants to adhere to the intervention and to complete the exercise diary. Education—management of physical symptoms encourages participation, which is key to behavioural change. Combination of education, peer support and relaxation results in positive health outcomes. Choice in relation to the type of exercise enhances adherence.	The relatively young age (mean—60 years) of participants when compared to the average age of the ovarian cancer population may have enabled engagement and increased adherence. 55% of participants did not have a tertiary-level education; this does not appear to have affected the outcomes in terms of recruitment, adherence and retention of participants. Stage of treatment—participants were post-aggressive treatment; physical function improved post-treatment, lack of treatment-related side effects perhaps contributed to adherence. Previous interest in exercise enhanced motivation to participate.
Mizahi et al. (2015). Sydney and Canberra, Australia. Objectives: To determine the feasibility of a combined supervised and home-based exercise intervention during chemotherapy for women with recurrent ovarian cancer; To ascertain the impact of physical activity on psychological outcomes and chemotherapy completion rates.	Population: Women with recurrent ovarian cancer receiving second- or third-line chemotherapy (n = 30). Setting: home-based and one supervised session weekly. Intervention: 12-week exercise program; Individualised exercise program—90 min or more per week of low-to-moderate aerobic, resistance core stability and balance exercise; Aerobic resistance core stability and balance exercise sessions, 10–40 min duration, 3–4 times per week; Balance exercises—for those experiencing neuropathy and at risk of falls; Aerobic exercise—walking, cycling or swimming; Weekly telephone call to monitor adherence and progress and discuss program progression.	Prospective single-arm trial. Moderate—no explanation provided in relation to the statistical test used.	Recruitment rate: 55%. Retention rate: 70%. Adherence rate: 81%. Quality of life (p = 0.003). Fatigue (p = 0.004). Mental Health (p = 0.007). Muscular strength (p = 0.001). Balance (p = 0.003). 24 week follow up—participants maintained their physical activity levels.	Incorporation of behavioural change strategies (goal setting, time management, identification of methods to overcome barriers) into the intervention. Additional factors that enhanced adherence: Engaging participants in both aerobic and resistance training; Weekly telephone calls to monitor adherence and progress; Requesting participants to complete a self-report physical activity diary; Once weekly supervised session; Engagement in programme did not negatively affect the chemotherapy completion; Choice regarding the type of exercise enhanced adherence.	The relatively young age (mean—59 years) of participants when compared to the average of the ovarian cancer population may have enabled engagement and increased adherence. Due to advanced disease, 10% of participants withdrew from the study as a result of fatigue, pain and anxiety. Lack of interest indicated as a reason for non-participation. Treatment-related side effects negatively affected participation and adherence.
Moonsmammy et al. (2013). Toronto, Canada. Objectives: To assess the safety and feasibility of a walking and CBT intervention prior to and after the completion of chemotherapy; To improve musculoskeletal and cardiovascular fitness.	Population: Women with recently diagnosed ovarian carcinoma stages III or IV. Patients were recruited over four months. 46 eligible patients; 13 declined (felt unable to commit, lived too far away, felt they were already too active, involved in another exercise programme); Researchers were unable to contact 14 patients. N = 19: Treatment group n = 7; Surveillance group n = 12. Attrition rate 26%—2 drop-outs, 1 loss to follow up and 1 disease recurrence. Setting: home-based. Exercise and CBT intervention 24-week home-based exercise intervention. Co-ordinated with 12 weeks of CBT. Exercise intervention: Exercise program delivered by a certified exercise physiologist; Moderate aerobic exercise and resistance training; Participants completed aerobic and resistance training on alternate days and recorded weekly activity in a detailed exercise manual. CBT intervention: CBT counselling completed via phone; One hourly session every second week.	Non-randomised Phase 2 trial. Moderate—no justifications provided for design; Small sample size unable to generalise findings.	Recruitment rate: not available. Retention rate: 26%. Adherence rate: Surveillance phase—83%; Treatment phase—56%. Significant increase in aerobic fitness—in both treatment and surveillance groups (p = 0.08). Modest increases in HRQOL in both treatment and surveillance groups (not statistically significant). Higher levels of confidence and self-efficacy in the surveillance group (not statistically significant). Reduced levels of depression and post-traumatic stress (not statistically significant). Adherence to the exercise program was not indicated.	Fortnightly telephone calls may have contributed to adherence. The completion of the exercise diary may have also contributed to adherence. Improvements were noted in relation to the self-efficacy and motivation of participants—CBT may have influenced these factors.	The relatively young age of participants (mean–treatment phase—53 years, surveillance phase—58 years) when compared to the average of the ovarian cancer population may have enabled engagement and increased adherence. 58% of participants had a tertiary-level education; this may have resulted in increased awareness regarding the importance of exercise and increased adherence to the intervention.
Newton (2011). Brisbane, Australia. Objectives: To assess the safety feasibility and potential effect of a walking intervention in women undergoing chemotherapy for ovarian cancer; To assess whether engaging in physical activity resulted in participants completing their chemotherapy treatment and increased quality of life, reduced levels of depression and increased physical functioning.	Population: Women newly diagnosed with ovarian carcinoma stage I [1], stage II [1], stage III [11], and stage IV [4]. 27 eligible (reasons for non-participation were not identified). N = 17 participants receiving chemotherapy: 3 receiving neo-adjuvant chemotherapy; 14 receiving adjuvant chemotherapy. Sixty-two women presenting with possible ovarian cancer at the participating hospital were screened over approximately 15 months. Setting: delivered in a clinical environment and home-based. Intervention: Individualised walking programme delivered prior to and for the duration of chemotherapy treatment; Patients were provided with an information booklet regarding the walking intervention; Participants completed an activity logbook; Sessions with exercise physiologist once weekly (face to face or via telephone); Sedentary women were instructed to begin by walking frequently (most days) but with lower-intensity shorter-duration (10 min) walks; Active women were initially instructed to maintain their current number of sessions and first increase the duration and later the intensity; During weekly sessions with an exercise physiologist presence, changes to treatment-related side effects identified as barriers to walking were discussed and resolved when possible details of the previous week’s walking sessions were discussed, the subsequent week’s walking targets were discussed and participants were also asked to indicate how they felt about participating in the walking program; Post-intervention assessment was conducted three weeks after the last dose of chemotherapy.	Non-randomised Phase 2 trial. Moderate.	Recruitment rate: 63%. Retention rate: 100%. Adherence rate: 90%. Improvements in physical functioning p = 0.01. Improvements in FACT-O p = 0.01. Physical well-being p = 0.08. Ovarian-specific concerns p = 0.04. Sixteen women (94%) completed and returned the intervention evaluation, all of whom found the program to be either helpful or very helpful. The vast majority (81%) rated the sessions with the exercise physiologist as very helpful. 75% considered the program to be excellent.	Discussions with the exercise physiologist regarding barriers to participation (nausea and diarrhoea) and identifying solutions (modifying walking route). Setting individualised training goals with the exercise physiologist. Home-based intervention may have enhanced adherence as women were able to engage in the programme at a time that suited them. 1 weekly supervised exercise session enhanced adherence. Combination of exercise and cognitive behavioural therapy resulted in positive health outcomes.	The relatively young age (mean—60 years) of participants when compared to the average of the ovarian cancer population may have enabled engagement and increased adherence to the intervention. 71% of participants had a tertiary-level education, which may have resulted in increased awareness regarding the importance of exercise and increased adherence to the intervention.
Von Gruenigen et al. (2011). Objective: To assess the feasibility of a lifestyle intervention for promoting physical activity and diet quality during adjuvant chemotherapy for ovarian cancer.	Population: Women with ovarian, fallopian tube or peritoneal cancer (stages I, II, III, IV). Mean age—59 years. Setting: home-based and clinical environment. Intervention: Combination of home-based and in the chemotherapy clinic; Patients were enrolled post-operatively and received physical activity and nutrition counselling at every chemotherapy visit for six cycles; Patients enrolled prior to chemotherapy starting; This intervention was based on previous interventions in breast cancer (Pierce et al. 2002) and endometrial cancer patients (Von Gruenigen et al. 2008); Participants were seen individually at each chemotherapy session, either before or during infusion by the study’s registered dietician; Each individual session lasted 30 min; Participants were given guidance specific to the intake of nutrient-dense foods and staying as physically active as possible; Participants were given pedometers and asked to complete a daily exercise and diet log; Participants were asked to be as physically active as possible; Questionnaires were completed at the beginning of each chemotherapy session.	Prospective single group trial of a nutrition and physical activity intervention in patients receiving at least 6 cycles of adjuvant chemotherapy. Moderate—small sample size.	Recruitment rate: 73%. Retention rate: not available. Adherence rate: 92%. Increase in physical activity cycle 3 to following cycle 6 was 61 min (p = 0.03) in cycle 3 to was 73 min (p = 0.082) in cycle 6. Increase in FACT-G p = 0.001. MSAS score p = 0.01. Increased moderate to strenuous physical activity was correlated with higher physical well-being during chemotherapy p = 0.037.	Setting of individualised goals may have increased adherence as participants had achievable targets. Discussing progress weekly enhanced adherence. The completion of daily activity logs and wearing pedometers. The authors theorised that increased physical activity may increase the quality of life (Stevinson et al. 2007) and the ability to tolerate chemotherapy and improve survival. Regular physical activity may increase the quality of life and reduce levels of fatigue and, subsequently, the ability to respond to and tolerate chemotherapy was enhanced. Participants were usually accompanied by a family member to the one-on-one sessions, therefore enhancing the participants’ motivation to adhere to the intervention.	The relatively young age (mean—59 years) of participants when compared to the average of the ovarian cancer population may have may have enabled engagement and increased adherence. 66% of participants had a tertiary-level education, which may have resulted in increased awareness regarding the importance of exercise and increased adherence to the intervention.
Zhang et al. (2018). China. Objective: To examine the feasibility of a nurse-led home-based exercise and cognitive behavioural therapy for ovarian cancer adults with cancer-related fatigue on outcomes of fatigue, sleep disturbance and depression.	Population: Ovarian cancer patients with stages I (n = 2), II (n = 10), III [33] and IV [21]; Recently post-surgery following a diagnosis of ovarian cancer; Patients with moderate [4,5,6] to severe [7,8,9,10] levels of fatigue (National Comprehensive Cancer Network 2011). Recruited to trial following the first cycle of adjuvant chemotherapy. Participants (n = 72): Randomly assigned to experimental group (n = 36) or comparison group (n = 36). Setting: 12-week home-based CBT and exercise intervention. Exercise intervention: Exercise—Walking or cycling; Patients were provided with an exercise manual and required to engage in aerobic physical exercise three to five times per week for twenty-five to sixty minutes per session; Aerobic and resistance training; Physical exercise 3–5 times per week for 25–60 min per session was recommended; The intensity of the exercise was gradually increased over the course of the intervention; Participants kept an exercise log; Weekly telephone contact from the research nurse to provide information regarding fatigue and to monitor exercise methods. CBT intervention: CBT intervention—delivered via internet sessions once weekly, 1 h each session for 12 consecutive weeks.	Randomised controlled trial. Moderate.	Recruitment rate: 92%. Retention rate: 92%. Adherence rate: T1—83.2%, T2—76.1%, T3—73.7%. Patients were deemed to adhere if they completed a minimum of 3 sessions per week for a 25 min duration per session. Fatigue: T1—Experimental group had statistically significant levels of behavioural (p < 0.001), sensory (p < 0.007) and cognitive (p < 0.036) fatigue; T2—no statistically significant reduction was noted in relation to affective fatigue; T3—Patient’s had statistically significant levels of behavioural (p < 0.001), sensory (p < 0.001) and cognitive (p < 0.001) fatigue. Depression: T2 and T3—experimental groups had statistically significant lower levels of depression (p ≤ 0.001). Strengths: The research nurses provided counselling regarding fatigue information, which may have helped with adherence to exercise intervention.	The use of the weekly telephone calls to monitor adherence to the exercise interventions and to provide motivational support may have positively impacted adherence to the intervention. Participants had an exercise manual to provide information in relation to the exercise intervention. Participants were required to complete an exercise diary. The research nurses provided counselling regarding fatigue information, which might have helped patients engage in physical activity intervention at home. Participants wore a Fitbit for the duration of the study.	The relatively young age (42% 55 years or younger) of the participants compared to the average of the ovarian cancer population may have may have enabled engagement and increased adherence.
Zhou et al. (2017). USA. Objective: Examine the effect of a six-month aerobic exercise intervention vs. attention control on the change in HRQOL and CRF in women diagnosed with ovarian cancer.	Population: 1-year post-diagnosis—diagnosed with ovarian cancer within last four years at the time of randomisation); All stages—I (n = 34) II (n = 30), III [5,8] and IV [21]; 54% of participants had stage III or stage IV cancer. Participants (n = 144)—mean age 57.3 + 8.6 years. Setting: home-based. Intervention: Exercise arm: Six-month home-based moderate-intensity aerobic exercise program (mainly brisk walking); 150 min of moderate-intensity aerobic exercise—mainly brisk walking; Weekly telephone calls to each participant from an American college of sports medicine certified cancer exercise trainer; Using a weekly 26-chapter book that the researchers developed; The trainer provided weekly individualised counselling via telephone to motivate participants to exercise; Seven-day activity log was used as the primary exercise adherence measure; Women wore heart monitors and were given a targeted heart range based on the Karvonen method for moderate-to-vigorous intensity; Participants recorded their exercise and heart rate in their daily activity log andreported this information to the exercise trainer during the weekly phone calls. Attention control arm: Received a weekly phone call from a WALC staff member, along with a 26-chapter book that contained ovarian cancer survivorship-related information.	Randomised controlled trial. Moderate.	Recruitment rate: not available. Retention rate: 78%. Adherence rate: Exercise—65%; Phone calls: 25 calls—19% (control arm) 47.3% (exercise arm); 20 calls—73.5% (control arm) 79.9% (exercise arm). Statistically significant improvement in the FACT-F (p < 0.02). Participants in the exercise arm who adhered to 80% or more of telephone calls had statistically significant improvement in FACT-F (p = 0.04). Participants in the attention control arm who adhered to 80% or more of the telephone did not have a statically significant improvement in FACT-F.	Motivational support via weekly telephone calls (boosted with 26-chapter book that contained motivational support) enhanced adherence. The additional supports, i.e., heart rate monitor and exercise diary, also assisted in motivating participants to adhere to the intervention. Weekly telephone calls focusing on participants’ adherence.	The relatively young age (mean age 55 years) of participants compared to the average of the ovarian cancer population may have enabled engagement and increased adherence. 39% of participants in the exercise arm had a tertiary-level education, which may have resulted in increased awareness regarding the importance of exercise and increased adherence to the intervention. 23% in the experimental arm had disease recurrence during intervention, which affected adherence.
Zhang et al. (2017). USA Objective: To establish the feasibility and acceptability of a 26-week home-based high dose exercise intervention among women with advanced-stage ovarian cancer.	Population: 10 women with advanced ovarian cancer at stages III and IV. Setting: home-based. Intervention: 26-week home-based high-dose exercise intervention of 225 min per week—moderate-intensity, mainly walking; All participants were provided with a walking program DVD and a physical activity tracker at their first in-person session; In-person exercise sessions were provided weekly for the first six weeks and monthly for the remaining 20 weeks by a certified clinical exercise trainer; Weekly telephone contact by a research staff member based on an interview script for the entire 26 weeks; Participants were asked each week whether they had any symptoms that prevented exercise; Participants were asked to keep an exercise log for the duration of the intervention; Participants wore an ACTi graph accelerometer for one week prior to the intervention and during the final week; Participants were asked to document in a diary provided accelerometer wear time.	Non-randomised. Pre-/post-test pilot study.	Recruitment rate: 50%. Retention rate: 80%. Adherence rate: 80%. During the 26 weeks, moderate-intensity exercise increased by 15 min per day (p = 0.05). The barriers to exercise indicated by participants were pain, neuropathy, lymphedema, life events stress and vacation. The mean number of steps per day increased from 948 to 1162.	In-person exercise sessions were facilitated by a certified exercise trainer. Individualised exercise plans. Participants wore a Fitbit for the duration of the study and an activity tracker for the first and final weeks of the study. Participants were asked weekly to indicate barriers that may have prevented them from exercising during the previous week.	The relatively young age (mean age 55 years) of participants compared to the average of the ovarian cancer population may have enabled engagement and increased adherence. Mean time since diagnosis—44 months, which may have resulted in positively impacting adherence as participants were more able to engage in the intervention. Temperature outside affected adherence—an increase in physical activity was associated with an increase in temperature.

Explanation of abbreviated terms: FACT-G—Functional Assessment of Cancer Therapy—General; HRQOL—health-related quality of life; FACT-F—Functional Assessment of Cancer Therapy—Fatigue; MSAS score—Memorial Symptom Assessment Scale; DVD—digital video disc; CBT—cognitive behavioural therapy.