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
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Copy igh : © 2022 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
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A ibu ion (CC BY) license (h ps://
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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 .
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