Breast Cancer Patients’ Experiences with Online Group-Based Physical Exercise in a COVID-19 Context: A Focus Group Study

  Ci a ion: Ga cia-Roca, M.E.; Rod iguez-A as ia, M.; Rope o-Padilla, C.; He nando Domingo, C.; Folch-Ayo a, A.; Temp ado-Albala , M.D.; Boldo-Roda, A.; Collado-Boi a, E. B eas Cance Pa ien s’ Expe iences wi h Online G oup-Based Physical Exe cise in a COVID-19 Con ex : A Focus G oup S udy. J. Pe s. Med. 2022,12, 356. h ps://doi.o g/10.3390/jpm 12030356 Academic Edi o : Eleano E. R. Ha is Recei ed: 19 Janua y 2022 Accep ed: 24 Feb ua y 2022 Published: 26 Feb ua y 2022 Publishe ’s No e: MDPI s ays neu al wi h ega d o ju isdic ional claims in published maps and ins i u ional a il- ia ions. Copy igh : © 2022 by he au ho s. Licensee MDPI, Basel, Swi ze land. This a icle is an open access a icle dis ibu ed unde he e ms and condi ions o he C ea i e Commons A ibu ion (CC BY) license (h ps:// c ea i ecommons.o g/licenses/by/ 4.0/). Jou nal o Pe sonalized Medicine A icle B eas Cance Pa ien s’ Expe iences wi h Online G oup-Based Physical Exe cise in a COVID-19 Con ex : A Focus G oup S udy Ma ia Elena Ga cia-Roca 1, Miguel Rod iguez-A as ia 1,2 , Ca men Rope o-Padilla 1,2,* , Ca los He nando Domingo 3,4 , Ana Folch-Ayo a 1,2 , Ma ia Dolo es Temp ado-Albala 5, Ana Boldo-Roda 6,7 and Eladio Collado-Boi a 1,2 1 Facul y o Heal h Sciences, P e-Depa men o Nu sing, Jaume I Uni e si y, 12071 Cas ello de la Plana, Spain; ga ci [email p o ec ed] (M.E.G.-R.); [email p o ec ed] (M.R.-A.); [email p o ec ed] (A.F.-A.); [email p o ec ed] (E.C.-B.) 2Resea ch G oup CYS, Facul y o Heal h Sciences, Jaume I Uni e si y, 12071 Cas ello de la Plana, Spain 3Spo Se ice, Jaume I Uni e si y, 12071 Cas ello de la Plana, Spain; [email p o ec ed] 4Depa men o Educa ion and Speci ics Didac ics, Jaume I Uni e si y, 12071 Cas ello de la Plana, Spain 5Depa men o Medicine, Ca denal He e a-CEU, CEU Uni e si ies, 46115 Valencia, Spain; [email p o ec ed] 6Depa men o Gynaecology and Obs e ics, La Plana Uni e si y Hospi al, 12540 Vila-Real, Spain; [email p o ec ed] 7Fisabio Founda ion, 46020 Valencia, Spain *Co espondence: ope [email p o ec ed] Abs ac : In pa ien s wi h b eas cance , physical exe cise educes he oxici y o ea men ; howe e , his physical exe cise mus mee a se o c i e ia, such as being guided by knowledgeable ins uc o s. Thus, he aim o his s udy was o explo e he pe cep ions o emale b eas cance pa ien s ega ding he impac o an online physical exe cise p og amme in he con ex o he COVID-19 pandemic. Nine een emale b eas cance pa ien s pa icipa ed in ou ocus g oup in e iews as pa o a quali a i e s udy using a hema ic analysis be ween Decembe 2020 and May 2021. Th ee majo hemes eme ged: “Expe iences and pe cep ions o online physical exe cise wi h b eas cance ”; “Inco po a ing exe cise-based ac i i y o cance - ela ed side e ec s”; and “Inc easing sel -es eem and empowe men ”. Online, li e-s eamed, and supe ised g oup ac i i ies help b eas cance pa ien s engage and p e en he ecu ence o cance - ela ed side e ec s, as well as o con ol COVID-19- ela ed ea and p o ide an al e na i e o p omo e men al heal h- ela ed quali y o li e. Keywo ds: ad e se e ec s; b eas cance ; COVID-19; exe cise; ocus g oups; women 1. In oduc ion Female b eas cance is one o he mos p e alen malignancies wo ldwide, accoun ing o 25% o all diagnosed cance s [ 1 ]. Cu en ly, he mos e ec i e o m o ea men is su ge y combined wi h complemen a y local he apies, such as adio he apy, o sys emic ea men s, such as chemo he apy, ho monal he apy, and a ge ed he apies [ 2 ]. Al hough he su i al a es in women diagnosed wi h cance con inue o inc ease, he ea men s ha a e adminis e ed o cu b disease p og ession ca y side e ec s ha a ec quali y o li e [ 3 ]. Su ge y can igge discom o a he su gical si e, he loss o muscle mass due o immobili y, and lymphedema seconda y o lymph node esec ion [ 4 ], while sys emic ea men s can p oduce long- e m side e ec s, such as ca diac oxici y, os eopo osis, and join pain, among o he s [5]. One s a egy o con ol he side e ec s o hese ea men s is he p esc ip ion o physical exe cise [ 6 ]. Se e al s udies ha e shown how physical exe cise educes he oxici y o ea men in pa ien s wi h b eas cance , imp o ing physiological and unc ional pa ame e s as well as quali y o li e [ 7 – 9 ]. As suppo ed by he In e na ional Agency o Resea ch on Cance (IARC), a physical exe cise egimen can be ou inely p esc ibed o women wi h J. Pe s. Med. 2022,12, 356. h ps://doi.o g/10.3390/jpm12030356 h ps://www.mdpi.com/jou nal/jpm J. Pe s. Med. 2022,12, 356 2 o 11 b eas cance bo h du ing ea men and a e wa ds, al hough hey mus mee a se ies o cha ac e is ics [ 8 , 10 ]. The sessions mus be guided by knowledgeable ins uc o s who a e capable o o e ing pe sonalised exe cise p og ammes wi h espec o he ype o umou , he ea men being adminis e ed, and he indi idual cha ac e is ics o each pa ien [11]. S ic isola ion and social dis ancing measu es we e implemen ed in esponse o he COVID-19 pandemic [ 12 – 14 ], pa icula ly a ec ing ulne able popula ions. In he case o cance pa ien s, cu backs we e made o he p esc ip ion o guided and supe ised physical exe cise, and ce ain clinical p ocedu es we e suspended o delayed [ 15 , 16 ]. Some s udies ha e shown he impo ance o designing g oup-based physical ac i i y p og ammes o p omo e men al heal h and esilience in cance su i o s [ 17 , 18 ]. Howe e , s udies on b eas cance pa ien s unde going ac i e ea men ha e ocused on he p esc ip ion o physical exe cise in pe son bo h indi idually and in small g oups [ 19 , 20 ]. Despi e he demons a ed e ec s o physical exe cise, o ou knowledge no s udy has quali a i ely esea ched he use o an online g oup exe cise p og amme wi h adap ed and indi idualised ollow-up in b eas cance pa ien s unde going ac i e ea men du ing he pandemic. 2. Ma e ials and Me hods 2.1. Aim The objec i e o his s udy was o explo e he pe cep ions o emale b eas cance pa- ien s unde going ea men ega ding he impac o an online physical exe cise p og amme on quali y o li e in he complex con ex o he COVID-19 pandemic. 2.2. Design To gain an in-dep h unde s anding o b eas cance pa ien s’ expe ience owa ds online g oup-based physical exe cise du ing he COVID-19 pandemic, he s udy adop ed a quali a i e app oach using ocus g oups in e iews [ 21 ]. This s udy was pe o med a Jaume I Uni e si y wi h emale b eas cance pa ien s unde going cance ea men be ween Decembe 2020 and May 2021. 2.3. Pa icipan s A pu posi e sampling app oach was used a Jaume I Uni e si y. The selec ion c i e ia included emale pa ien s who: (i) we e 18 o olde ; (ii) we e diagnosed wi h b eas cance (ICD-10: C50 o ICD-9: 174, 175, and V10.3) unde going cance ea men (chemo he - apy, ho mone he apy, o immuno he apy); (iii) pa icipa ed in bi-weekly online physical aining in s eaming o e ed by M.E.G.-R. and supe ised by hei oncology eam o a leas 6 mon hs; and (i ) p io o aking pa in his esea ch ag eed o p o ide w i en in o med consen . 2.4. P ocedu e An online physical exe cise p og am was designed o inc ease s eng h, join mobili y, and ca dio ascula capaci y, wi h he pu pose o imp o ing quali y o li e by inc easing pa ien s’ ole ance o cance ea men s. This p og amme, deli e ed ia s eaming as a esul o he pandemic, was designed by a mul idisciplina y eam ( wo g adua es in physical ac i i y and spo wi h a specialisa ion on oncology, wo medical oncologis s, wo specialis s in gynaecological and b eas su ge y, wo doc o s in heal h sciences and one psycho-oncologis ) o allow pa icipan s o bene i om physical exe cise supe ised and di ec ed by a specialised p o essional. A o al o 25 women pa icipa ed in he physical exe cise p og am and we e di ided in o wo homogeneous g oups based on age and physical i ness a iables, he alues o which we e ob ained om baseline measu emen s. Ae obic capaci y (walking es ), s eng h (s and chai , hand g ip, and squa jump es ), lexibili y (si and each es ), and daily physical exe cise we e he a iables s udied (con inuous moni o ing wi h accele ome e y o 7 days). Each o hese g oups was u he di ided in o wo g oups pe schedule, yielding wo g oups o eigh pa ien s, one g oup o six pa ien s, and one g oup o i e pa ien s. The J. Pe s. Med. 2022,12, 356 3 o 11 equency o he p og amme was wo 60 min sessions pe week. Se en y-six pe cen o he pa icipan s (n= 19) comple ed he en i e p og am, while 24% (n= 6) d opped ou ; eigh pe cen o he pa icipan s (n= 2) d opped ou due o disease p og ession, ano he 8% ( n= 2 ) due o scheduled su ge y, and he emaining pa icipan s (n= 2, 8%) ga e no eason. The women who comple ed he p og am (n= 19) a ended 95% o he scheduled sessions. The physical exe cise p og am consis ed o 48 sessions sp ead ou o e six mon hs. The sessions we e spli in o h ee sec ions. The i s en minu es o he wa m-up we e spen doing join mobili y exe cises. The main pa was 40 min o s eng h- esis ance wo k (e.g., squa s, on and side lunges, si -ups, biceps, iceps, e c.). The inal 10 min segmen included lexibili y exe cises o he la ge muscle g oups. A he end o he session, a a igue scale (Bo g scale) was applied, and he in ensi y o he subsequen sessions was p og ammed based on he pe cen age o a igue eached. The in ensi y was adap ed o each a igue alues o 60 o 75% in he wo subg oups ha ob ained be e alues o he physical a iables in he baseline measu emen , while he wo subg oups wi h lowe alues wo ked a in ensi ies ha esul ed in a igue alues o 50 o 70%. 2.5. Da a Collec ion Fou ocus g oup in e iews (FGs), wi h 4 o 5 emale pa ien s pa icipa ing in each in e iew, we e ca ied ou . Resea che s de eloped and ag eed on an in e iew p o ocol designed o encou age pa icipan s o gi e de ailed esponses (Table S1). All he in e iews we e conduc ed a Jaume I Uni e si y by wo esea che s expe ienced in conduc ing quali a i e in e iews wi h oncology pa ien s, and in acco dance wi h COVID-19 capaci y and sa e y p o ocols. Each in e iew las ed 40 o 60 min and he audio was digi ally eco ded. Da a collec ion was con inuously analysed un il da a sa u a ion was eached. To ensu e he anonymi y o he pa icipan s in he ansc ip ion o he in e iews, he le e s “G” (g oup) and “P” (pa icipan s) we e employed, along wi h he pa icipan numbe . P io o he analysis, he pa icipan s we e gi en he op ion o e iewing he ansc ip s. 2.6. Da a Analysis All in e iews we e ansc ibed and anonymised p io o hei analysis wi h he AT- LAS. i 9 so wa e. In his ega d, a hema ic analysis elabo a ed by B aun and Cla ke [ 22 ] was used, which con ains he ollowing s eps: (i) da a amilia isa ion by eading all an- sc ip s epea edly, (ii) a anging pe inen da a in o signi ican codes, and (iii) g ouping he codes in o possible hemes. La e , (i ) hema ic alidi y is con i med by eading all codes and he en i e da a se , ( ) be o e de ining and naming hem, and ( i) elabo a ing a inal epo (Figu e 1). J. Pe s. Med. 2022, 12, x FOR PEER REVIEW 4 o 12 Figu e 1. Concep ual map based on emale b eas cance pa ien s’ expe iences wi h physical exe cise du ing he COVID-19 pandemic ([]—is pa o ; = =—is associa ed wi h; = >—is a cause o ). 2.7. E hical Conside a ions The E hics Commi ee o Jaume I Uni e si y app o ed he s udy, which adhe ed o all o he p inciples o he Helsinki Decla a ion and i s subsequen e isions. Be o e con- duc ing he s udy, pa icipan s p o ided in o med consen and he da a collec ion design ensu ed con iden iali y and anonymi y. Pa icipan s we e also no i ied ha hei expe i- ences, opinions, and pe spec i es would no a ec hei academic g ades. 2.8. Rigou This s udy was de eloped using he ecommenda ions o he consolida ed c i e ia o epo ing quali a i e esea ch (COREQ) [23]. Two au ho s (M.E.G.-R. and M.R.-A.) in- di idually analysed w i en desc ip ions be o e mee ing oge he o con as , associa e, and deba e he eme ging hemes in o de o a ain con o mabili y. In he e en o a dis- c epancy, a hi d esea che (C.R.-P.) was consul ed o ensu e ha he collec ed da a we e eliable and consis en . 3. Resul s 3.1. Pa icipan Cha ac e is ics A o al o 19 emale b eas cance pa ien s pa icipa ed in ou FGs conduc ed in May 2021. The pa icipan s’ a e age age was 49.2 yea s old (SD = 9.2), wi h a ange o 28 o 66. The mos equen umou s age was s age II wi h 63.1% (n = 12) o he pa icipan s. A o al o 84.2% o he pa icipan s (n = 16) ecei ed su ge y and 42.1% (n = 8) ecei ed chem- o he apy (doxo ubicin and cyclophosphamide) in addi ion o adio he apy. The quali a- i e analysis disclosed h ee majo hemes, which a e p esen ed in Table 1. Table 1. Themes, sub- hemes, and ep esen a i e quo es. Main Themes Sub-Themes Rep esen a i e Quo es Expe iences and pe cep- ions o online physical exe cise wi h b eas can- ce Belie s and expec a- ions abou physical ex- e cise “Spo has p o ided me wi h a le el o suppo ha I could ne e ha e imagined. When hey asked me, “do you wan o be a pa o his exe cise g oup?”, I did no hesi a e. I needed i emo ionally and physically. I el somehow sa ed, and when I s a ed, i was an- as ic” G1-P3 “I knew I wan ed o keep doing spo s because I know i gi es me bo h emo ional and physical s abili y. Ha ing o lea e my paddle eam in o de o lock mysel away a home and do no hing ha mo i a ed me has made joining his g oup a li e-changing expe ience” G4-P1 Figu e 1. Concep ual map based on emale b eas cance pa ien s’ expe iences wi h physical exe cise du ing he COVID-19 pandemic ([]—is pa o ; = =—is associa ed wi h; = >—is a cause o ). J. Pe s. Med. 2022,12, 356 4 o 11 2.7. E hical Conside a ions The E hics Commi ee o Jaume I Uni e si y app o ed he s udy, which adhe ed o all o he p inciples o he Helsinki Decla a ion and i s subsequen e isions. Be o e conduc ing he s udy, pa icipan s p o ided in o med consen and he da a collec ion design ensu ed con iden iali y and anonymi y. Pa icipan s we e also no i ied ha hei expe iences, opinions, and pe spec i es would no a ec hei academic g ades. 2.8. Rigou This s udy was de eloped using he ecommenda ions o he consolida ed c i e ia o epo ing quali a i e esea ch (COREQ) [ 23 ]. Two au ho s (M.E.G.-R. and M.R.-A.) indi idually analysed w i en desc ip ions be o e mee ing oge he o con as , associa e, and deba e he eme ging hemes in o de o a ain con o mabili y. In he e en o a disc epancy, a hi d esea che (C.R.-P.) was consul ed o ensu e ha he collec ed da a we e eliable and consis en . 3. Resul s 3.1. Pa icipan Cha ac e is ics A o al o 19 emale b eas cance pa ien s pa icipa ed in ou FGs conduc ed in May 2021. The pa icipan s’ a e age age was 49.2 yea s old (SD = 9.2), wi h a ange o 28 o 66. The mos equen umou s age was s age II wi h 63.1% (n= 12) o he pa icipan s. A o al o 84.2% o he pa icipan s (n= 16) ecei ed su ge y and 42.1% (n= 8) ecei ed chemo he apy (doxo ubicin and cyclophosphamide) in addi ion o adio he apy. The quali a i e analysis disclosed h ee majo hemes, which a e p esen ed in Table 1. Table 1. Themes, sub- hemes, and ep esen a i e quo es. Main Themes Sub-Themes Rep esen a i e Quo es Expe iences and pe cep ions o online physical exe cise wi h b eas cance Belie s and expec a ions abou physical exe cise “Spo has p o ided me wi h a le el o suppo ha I could ne e ha e imagined. When hey asked me, “do you wan o be a pa o his exe cise g oup?”, I did no hesi a e. I needed i emo ionally and physically. I el somehow sa ed, and when I s a ed, i was an as ic” G1-P3 “I knew I wan ed o keep doing spo s because I know i gi es me bo h emo ional and physical s abili y. Ha ing o lea e my paddle eam in o de o lock mysel away a home and do no hing ha mo i a ed me has made joining his g oup a li e-changing expe ience” G4-P1 A g oup-based exe cise p og amme o ocus on heal h no illness “I would no ha e done i on my own i I hadn’ been in a g oup. This has been highly help ul o me; wi hou i , I belie e I would ha e collapsed somehow” G3-P5 “Today, he bes way o me is o do i as a g oup. Because looking a he one who does be e s imula es me and helps me s i e o achie e highe goals, because you eel accompanied and en iched by he o he s” G2-P3 Inco po a ing exe cise-based ac i i y o cance - ela ed side e ec s Bene i s and d awbacks o s uc u ed and supe ised aining “Wi h he pain and a igue, you hink you can’ do i because you a e oo weak. Howe e , you make he ex a e o wi h his aining and i gi es you he ene gy o keep going and no lie in bed all day” G3-P4 “The e has been a comple e be o e and a e . I belie e his aining has helped me in a oiding he “I can’ ” ci cle. I has gi en me he con idence o say, “yes, I can, I can do his, and I will ge i back” G4-P2 Con inui y o imp o e physical and psychological well-being “I now do exe cise e e y day, and he days I don’ , I miss i . I didn’ go ou much be o e, and I s ill don’ go ou much now, bu I eel a lo be e . I don’ hink abou any hing nega i e, and I a ely conside cance . I am h illed and g a e ul” G1-P5 “When I p epa e my weekly schedule, I include hings like “ his ime o walk o he moun ain, his ime o he exe cises...” I now include i in my plans, which I ne e used o do be o e” G3-P3 Inc easing sel -es eem and empowe men Physical exe cise o add ess sel -compassion “Being able o i ually in e ac wi h a g oup wi h whom you can sha e expe iences, he impac o seeing you sel hai less... I belie e ha seeing ha we a e all going h ough his oge he , exe cising oge he , always helps psychologically. I suppo s you in assimila ing o he en i e si ua ion you a e expe iencing” G2-P4 “I el iden i ied, as hough I wasn’ he only one who el he same way. The g oup encou ages, suppo s, accompanies, mo i a es, li s you up, and d i es you o achie e and challenge you sel o ul il he goals” G4-P3 Psychological impac o he COVID-19 pandemic “This ime we all had o exe cise oge he made you o ge abou he COVID-19 si ua ion, o no being able o see iends o amily. You hink abou o he hings, like how s ong you eel, o how you a e a emp ing an exe cise ha you couldn’ do i be o e, and now you could li my a m highe ” G1-P3 “I used o walk om he balcony o he dining oom, hen om he dining oom o he bed oom... I was hea b oken by he ac ha I couldn’ go ou in public because o he pandemic. I can ell you ha his g oup exe cise ime has been a gamechange o me” G2-P1 J. Pe s. Med. 2022,12, 356 5 o 11 3.2. Theme 1: Expe iences and Pe cep ions o Online Physical Exe cise wi h B eas Cance This i s heme add esses wo sub- hemes and depic s he pa icipan s’ expec a ions and expe iences wi h an online g oup-based physical exe cise p og amme while unde go- ing cance ea men du ing he COVID-19 pandemic. In pa icula , ou da a e ealed he po en ial e ec s o his g oup-based physical exe cise p og amme on pa ien s’ well-being du ing cance ea men . 3.2.1. Sub-Theme 1.1: Belie s and Expec a ions abou Physical Exe cise Physical exe cise du ing cance ea men was some hing ha some pa icipan s had no p e iously conside ed o be bene icial o he cance disease p ocess. In ac , he pa icipan s emphasised he signi icance o he b eas oncology eam’s ecommenda ion o physical exe cise while unde going cance ea men in o de o eel i was a pa o he ea men . On he o he hand, o he s we e con inced ha spo s we e bene icial o hem, bu go e nmen es ic ions imposed as a esul o he COVID-19 pandemic o ced hem o o ego some o hei spo s ac i i ies: “I wouldn’ ha e conside ed spo s o be a co e elemen o my ea men , bu I belie e i also has an impac on who makes he ecommenda ion. You so o say, “hey, his looks like a ea men ”. T ue, i is a di e en kind o ea men , bu when a heal h p o essional says so, i is because i is going o help me. Being hones , I ake i in o accoun mo e han i someone else who isn’ a heal hca e p o essional says i ” G4-P4 “I ha e always been ac i e, bu since being diagnosed wi h b eas cance , I ha e become mo e cau ious in all aspec s o my li e, especially wi h he COVID-19... I couldn’ isk going o he gym, so when I hea d abou he online g oup, I hough i was pe ec because i was abou much mo e han jus doing spo by my own; i was abou being able o speak wi h o he people who a e dealing wi h he same hing as you, a wo- o -one, spo and g oup he apy wi h people who ha e you same issues” G2-P3 3.2.2. Sub-Theme 1.2: A G oup-Based Exe cise P og amme Expe ience o Focus on Heal h No Illness Likewise, he majo i y o he pa icipan s s a ed ha aking pa in a well-planned and o ganised online g oup-based physical exe cise p og amme, as well as ha ing a knowledge- able ins uc o and being supe ised, was an impo an ac o in eeling mo i a ed, being pe son-cen ed ca ed, and being able o socialise and empa hise wi h he o he women: “I is well wo h i . I genuinely hink ha spo is e y essen ial, bu I also belie e ha he ins uc o ’s wo k is impo an , when she said o us, “come on, you a e doing e y well”; aside om he exe cise, i is he mo i a ion ha you had du ing ha ime, i was a he apy, i was supe ised, and he e was eedback o wha we we e doing. The e is a pe son who is ollowing you, who is ollowing you up” G1-P1 “This exe cise p og amme has been a huge li esa ing boa o me ha allowed me o in e ac wi h o he s who ga e me a lo and helped me no o make he day- o-day li e o being alone so challenging. I had my ime o sociabili y, my ime o alk wi h he ins uc o , mi iga ing all o he nega i e aspec s o he pandemic” G3-P2 3.3. Theme 2: Inco po a ing Exe cise-Based Ac i i y o Cance -Rela ed Side E ec s This second heme iden i ies he impo ance o pa icipa ing in a g oup-based exe cise p og amme du ing cance ea men o pa ien s’ biopsychosocial well-being, as well as how his expe ience helps hem p omo e and engage in physical exe cise in hei daily li es. 3.3.1. Sub-Theme 2.1: Bene i s and D awbacks o S uc u ed and Supe ised T aining Many o he pa icipan s emphasised ha his g oup-based physical exe cise expe i- ence had an impac on e e y aspec o hei li es, bu mos no ably on he elie o cance ea men side e ec s, such as pain, i edness, mo i a ion, and a i ude and beha iou p oblems, among o he s: J. Pe s. Med. 2022,12, 356 6 o 11 “I used o ha e o go o bed because I was in so much agony. “I’m s ill and I’m exhaus ed!” I c ied. The nex day, I was unable o do any hing. Howe e , you ge up, wa m up, and exe cise a he s a o he supe ised exe cise p og amme... O cou se, you ge i ed, bu you es a li le, and he nex day, you eel g ea . I’ e been pe o ming he exe cise aining o mon hs, and I’ e ound ha he pain e u ns a e 2–3 days o no doing i , so I ha e o keep doing i !” G2-P1 “My join s hu when I i s s a ed he aining p og amme, I had mo e ho lashes, and I could ha dly sleep. Ye , I ha e almos no ho lashes, no join pain, and I sleep a lo be e wi h his ea men and exe cise ou ine. My quali y o li e has imp o ed signi ican ly, so I in end o con inue he supe ised p og amme” G1-P5 Despi e he o e all bene i s o online g oup-based exe cise aining, he lack o physical in e ac ion and ace- o- ace ac i i ies was he mos signi ican disad an age o pa icipan s: “I ha e missed being able o ge oge he and spend some ime con e sing wi h o he s a e he aining class. The COVID-19 pandemic made me ealise how much I need physical con ac ; I enjoy in e ac ing wi h o he s and ha ing a chi -cha e e y now and hen” G3-P4 “No seeing each o he , no laughing when we a e knacke ed and soaked in swea ... De ini ely, he main d awback o me was ha he e is no physical con ac ” G4-P2 3.3.2. Sub-Theme 2.2: Con inui y o Imp o e Physical and Psychological Well-Being One o he aspec s mos equen ly men ioned by pa icipan s was how hei physical and psychological well-being imp o ed du ing his supe ised g oup-based physical exe cise expe ience, p omp ing hem o in oduce exe cise in o hei daily ou ine as any o he impo an aspec o li e and ensu e adhe ence o physical exe cise: “I said a he beginning “Wha a hassle, bu well . . . Le ’s see i I can make i h ough he nex six mon hs”. Now, when we a e no wi h he ins uc o , I am wo king ha d as well. I will ne e s op because he di e ence be ween how I used o be and how I am now is b ea h aking. I eel s ong and, mos impo an ly, con iden since my bigges anxie y was wi h my bones, and now ha I ha e he muscles o suppo e e y hing, i o e s me a lo o peace o mind” G3-P1 “Al hough he e a e days when I am exhaus ed because my medica ion o ha e hings o do, i is ue ha I ha e made physical exe cise a pa o my daily ou ine. My quali y o li e has d as ically imp o ed, i is like my ea men now... And i has in luenced o he s o suppo me. We a e mo ing like chess pieces so his, which is a p io i y o me, can keep going” G1-P2 3.4. Theme 3: Inc easing Sel -Es eem and Empowe men The las heme o e s some insigh in o he impo ance o g oup-based physical ex- e cise in which all he pa icipan s sha e simila cha ac e is ics, allowing hem o ela e hei expe iences wi h he cance disease and ea men p ocess and suppo each o he . In e es ingly, he pa icipan s also iden i ied o he pe ks, such as how pa icipa ing in an online physical exe cise aining en i onmen made hem eel sa e om in ec ion du ing he COVID-19 pandemic. 3.4.1. Sub-Theme 3.1: Physical Exe cise o Add ess Sel -Compassion A la ge numbe o pa icipan s desc ibed how sha ing his exe cise p og amme wi h o he women expe iencing simila disease symp oms made hem eel accompanied, unde - s ood, and s onge in hei igh agains cance : “I belie e ha in his disease, he suppo be ween each o he is c i ical. I belie e ha when we a e all in he same si ua ion, he amoun o empa hy ha can be awakened among us inc eases eno mously. I don’ eel you iends o amily uly comp ehend wha is happening o you. When we alk, you a e ne e deligh ed ha he o he pe son is J. Pe s. Med. 2022,12, 356 7 o 11 also hu ing, bu you a e soo hed by he no ion ha you bones hu because we all do” G4-P5 “Doing he exe cise p og amme and deciding o o m a g oup in which we could exp ess ou eelings, wha was going on in ou li es, and e en laughed a ou sel es. Tha was hugely help ul o my sel -es eem since we could no malise he si ua ion. We cha ed abou wha was going on wi h us, ou ea s, and ou ejec ion o ou own image . . . We encou aged one ano he , we suppo ed each o he . Joining he g oup has been a libe a ing expe ience o me” G2-P4 3.4.2. Sub-Theme 3.2: Psychological Impac o he COVID-19 Pandemic One o he key opics was he online app oach o he g oup-based physical exe cise p og amme in which he women pa icipa ed ha allowed hem o eel ea less and sa e om in ec ion, despi e he immunosupp ession induced by cance ea men . Al hough hey we e pa icula ly conce ned abou COVID-19 in ec ion since i would hal hei cance ea men , he online i ness p og amme appea ed o be a use ul al e na i e o balancing physical exe cise wi h amily, job, and o he esponsibili ies: “The COVID-19 ho i ied me; i you go i , you ea men would be delayed, which was un hinkable o me. To be hones , I el eally alone, bu I s a ed wi h his online exe cise aining he e and g adually imp o ed. You can see ha he e a e mo e people like you; hus, you mus pa icipa e in ac i i ies and keep mo ing o wa d. I i had been in pe son, I would no ha e gone ou o ea , bu a he ou o cau ion” G1-P4 “I ind he ac ha i was done in s eaming was ex emely posi i e because I eel ha all o us we e wo ied o he COVID-19 du ing ou chemo he apy o adio he apy p ocess. Be ween ha ea and pe sonal ci cums ances such as kids, jobs, a el and ime cons ain s, i was a posi i e change o do i in s eaming” G2-P2 4. Discussion This s udy aimed o explo e b eas cance pa ien s’ pe cep ions owa ds he impac o online physical exe cise in hei quali y o li e whils ecei ing cance ea men h ough he unde s anding o hei expe iences in a complex scena io as a consequence o he COVID-19 pandemic. Following he analysis o ou indings, i was ound ha almos all pa icipan s epo ed a e amped engagemen , mo i a ion, and sel -es eem wi h he use o he online supe ised g oup-based exe cise aining. Al hough he impo ance o exe cise o women du ing b eas cance su i o ship has been discussed [ 24 – 26 ], his s udy yielded some in e es ing indings ega ding he impac o an online g oup-based exe cise p og amme o op imise adhe ence. To he bes o ou knowledge, his is he i s s udy o explo e emale b eas cance pa ien s’ expe iences ega ding ba ie s and mo i a o s o physical exe cise du ing he COVID-19 pandemic whils ecei ing ea men o b eas cance om a quali a i e pe spec i e. Ou indings, simila o hose o ace- o- ace aining p og ammes, showed ha s uc- u ed and supe ised online exe cise aining is a sa e s a egy o b eas cance pa ien s, o e ing imp o emen s in i ness, physiological and psychological unc ions, and cance - ela ed side e ec s [ 25 , 27 ]. Al hough emale b eas cance pa ien s a e gene ally mo i a ed o s ay heal hy, inaccu a e belie s and mispe cep ions abou physical exe cise appea o be a ba ie o pa icipa ing in exe cise [ 28 ]. Indeed, b eas cance pa ien s’ p e-exis ing belie s, alues and a i udes owa ds physical exe cise end o be simila o hose a ec ing he gene al popula ion, and a lack o accu a e in o ma ion abou sa e exe cise in luences hei decisions ega ding exe cise, despi e i s well-documen ed bene i s [ 29 ]. One possible explana ion o his could be he manne in which physical exe cise and ea men egimens a e o e ed o women and ela i es, which is some imes associa ed wi h he non-essen ial aspec s o ea men s [30,31]. In con as o ecen s udies [ 32 , 33 ], mos pa icipan s belie ed ha he supe ised g oup-based physical aining p og amme imp o ed hei ene gy le els and well-being. J. Pe s. Med. 2022,12, 356 8 o 11 Fo ou pa icipan s, g oup dynamics could be as e ec i e as an indi idual exe cise in imp o ing hei quali y o li e, as hey a e able o engage socially whils aining. While he le el o physical exe cise expe ience a ied among ou pa icipan s, ha ing a knowl- edgeable ins uc o along wi h hei b eas oncology eam helped in ailo ing app op ia e physical g oup-based ac i i ies [ 6 ]. Ce ainly, he impo ance o g oup-based exe cise in en- cou aging con inui y and p omo ing pee social suppo wi h o he s was he mos posi i e aspec highligh ed in ou indings [ 26 , 34 , 35 ]. As ou pa icipan s epo ed, hese online and supe ised g oup-based physical ac i i ies p o ided a sa e and ca ing en i onmen du ing a ime o mobili y es ic ions due o he COVID-19 pandemic, and assis ed in o e - coming p e iously epo ed hu dles, such as bad wea he , cos s, o ime cons ain s [ 36 ]. These indings u he suppo o he ideas o sel -de e mina ion heo y and achie emen goal heo y [ 37 , 38 ], which ad oca e o he use o g oup-mo i a ed cogni i e-beha iou al in e en ions, such as sel -moni o ing, goal se ing, suppo , eedback, and elapse in- e en ion, and sugges ha a ask-o ien ed en i onmen can imp o e mo i a ion and adhe ence [ 39 ]. Fu he mo e, ecen esea ch indica es ha in e en ions which os e a posi i e, ask-o ien ed, and ca ing en i onmen du ing b eas cance ea men esul in inc eased mo i a ion, posi i e a i udes owa ds exe cise, and op imism among pa- ien s [ 40 ]. An implica ion o his emo ional posi i e expe ience is he possibili y ha a ca ing and supe ised aining exe cise may help b eas cance pa ien s imp o e hei psychological adjus men ia sel -compassion [ 41 ]. Sho - e m and long- e m g oup-based physical exe cise p og ammes ha e been shown o educe anxie y, dep ession, o body im- age dis u bance, and may he e o e cons i u e a good oppo uni y o os e sel -compassion cul i a ion in pa ien s unde going ea men o b eas cance [25,42]. Tha being said, ou pa icipan s highligh ed no el and speci ic psychological implica- ions o he COVID-19 pandemic on hei quali y o li e. Aside om p e iously documen ed cance - ela ed side e ec s, such as uppe ex emi y issues, a igue, pain, dep ession, o body image dis u bance [ 24 , 43 ], ea was he mos common conce n among pa icipan s. This ea was clea ly d i en by he possibili y o delays o e en dis up ions in cance ca e as a esul o he ela i e isks o COVID-19 exposu e [ 44 ]. In his sense, no only did online and supe ised g oup-based ac i i ies assis pa ien s in engaging and p e en ing he ecu ence o cance - ela ed side e ec s, bu hey also con olled COVID-19- ela ed ea and p o ided an al e na i e o p omo e men al heal h- ela ed quali y o li e. This is in acco dance wi h ea lie obse a ions, which showed ha online, web-based, and digi al in e en ions ha e po en ial o physical exe cise p omo ion among cance pa ien s [ 45 , 46 ], hough a mo e sus ained and di ec ins uc o - o-g oup app oach, as sugges ed by ou pa icipan s, would be equi ed. Ne e heless, he e a e ce ain limi a ions ha should be conside ed. To da e, he e is limi ed esea ch in es iga ing he impac o physical exe cise on emale b eas cance pa ien s ecei ing cance ea men , which has limi ed he discussion o ou indings. Fu u e esea ch should explo e he expe iences and pe cep ions o ins uc o s in o de o gain a deepe unde s anding o he use o g oup-based physical exe cise p og ammes, as well as possible al e na i es o he iden i ied d awbacks. Mo eo e , hese indings wa an u he discussion, o example, su ounding he inclusion o p esc ibed exe cise p og ammes in o cance ca e ea men s o he use o g oup-based p og ammes wi h o he ypes o cance s. 5. Conclusions Ou indings indica e ha g oup-based physical exe cise has he po en ial no only o ins il sel -es eem and add ess sel -compassion, bu also empowe women o be con iden du ing hei ea men and p e en cance - ela ed side e ec s. Gi en he physical and psychological heal h bene i s o egula physical exe cise o his popula ion, p omo ing physical ac i i y in women diagnosed wi h and being ea ed o b eas cance mus be an essen ial public heal h p io i y. Cance ca e eams and expe ienced ins uc o s may acili- a e pe son- and cance -cen ed ca e in a imely, accu a e, and ailo ed manne , whe eby p o iding a ca ing and g oup-based suppo i e clima e may o e a sa e en i onmen in J. Pe s. Med. 2022,12, 356 9 o 11 which b eas cance pa ien s can eel com o able, engage socially, and acqui e exe cise adhe ence. Thus, online and li e-s eamed physical exe cise p og ammes a e a iable ap- p oach o p omo ing physical and men al well-being among emale b eas cance pa ien s while hey a e unde going ea men . Supplemen a y Ma e ials: The ollowing suppo ing in o ma ion can be downloaded a : h ps: //www.mdpi.com/a icle/10.3390/jpm12030356/s1, Table S1: In e iew p o ocol o ocus g oups. Au ho Con ibu ions: Concep ualiza ion, M.E.G.-R., M.R.-A., C.R.-P. and E.C.-B.; me hodology, M.E.G.-R., M.R.-A., C.R.-P., C.H.D., A.F.-A., M.D.T.-A., A.B.-R. and E.C.-B.; in es iga ion, M.E.G.-R., M.R.-A., C.R.-P., C.H.D., A.F.-A., M.D.T.-A., A.B.-R. and E.C.-B.; alida ion, M.E.G.-R., M.R.-A., C.R.-P. and E.C.-B.; o mal analysis, M.E.G.-R., M.R.-A., C.R.-P. and E.C.-B.; w i ing—o iginal d a , M.E.G.- R., M.R.-A., C.R.-P. and E.C.-B.; w i ing— e iew and edi ing, M.R.-A. and C.R.-P.; isualiza ion, M.R.-A. and C.R.-P.; supe ision, C.H.D., A.F.-A., M.D.T.-A. and A.B.-R.; p ojec adminis a ion, M.E.G.-R. and E.C.-B. All au ho s ha e ead and ag eed o he published e sion o he manusc ip . Funding: This esea ch was unded by he LecadóFounda ion; he Fisabio Founda ion; he Ca hed a o Physical Ac i i y and Oncology JoséSo iano Ramos Founda ion; and he Ca hed a Enda an Villa eal Founda ion (g an numbe e . UJI-A2017-06). Ins i u ional Re iew Boa d S a emen : This s udy was app o ed by he E hics Commi ee o Jaume I Uni e si y (Re . UJI-A2017-06). In o med Consen S a emen : In o med consen was ob ained om all subjec s in ol ed in he s udy. Da a A ailabili y S a emen : The da a ha suppo he indings o his s udy a e a ailable on eques om he co esponding au ho . The da a a e no publicly a ailable due o p i acy o e hical es ic ions. Con lic s o In e es : The au ho s decla e no con lic o in e es . Re e ences 1. B ay, F.; Fe lay, J.; Soe joma a am, I.; Siegel, R.L.; To e, L.A.; Jemal, A. Global Cance S a is ics 2018: GLOBOCAN Es ima es o Incidence and Mo ali y Wo ldwide o 36 Cance s in 185 Coun ies. CA Cance J. Clin. 2018,68, 394–424. [C ossRe ] [PubMed] 2. Domaszewska, K.; Janiak, A.; Podgó ski, T.; Demu h, A.; K y´sciak, J.; Pe kowski, P.; Cze niak, U. A Pilo S udy o In luence o Endu ance T aining on he P ooxida i e and An ioxidan S a us o Women a e B eas Cance . In . J. En i on. Res. 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