Perceptions of older women with cancer participating in an exercise programme: a mixed methods pilot study

Abstract

Fourteen women over the age of 55 years with a history of cancer were followed during and after completion of a monitored exercise programme intended to improve body strength, functional performance, balance, activities of daily living and quality of life. A sequential explanatory mixed methods design was employed. The quantitative strand utilised a quasi-experimental, pretest/posttest design. The qualitative strand involved individualised interviews 2–3 months following completion of the intervention. The main outcomes were (a) physical characteristics of participants; (b) resistive tests; (c) functional ability; (d) cancer-related fatigue and (e) quality of life. Both study strands indicated that all participants showed significant improvement in resistive tests, functional ability and activities of daily living. Though quantitative results of fatigue and quality of life were statistically nonsignificant, qualitative findings indicated clinically significant improvement.

Keywords

cancer exercise mixed methods older women quality of life

Introduction

This year an estimated 1,685,210 new cancer cases will be diagnosed in the USA, 843,820 of whom are women facing the challenge of living with cancer (American Cancer Society, 2016). Historically, nearly 100% of women with cancer are plagued by troubling and debilitating physical and psychosocial side effects related to the disease and its treatment. Side effects include severe chronic fatigue, loss of appetite, peripheral neuropathy, osteoporosis, pain and depression. Seminal studies have demonstrated that exercise may alleviate many of the side effects associated with the diagnosis and treatment of cancer, thus improving the patient’s physical and psychosocial quality of life (Hanna et al., 2008). Systematic reviews and meta-analyses (Gerritsen and Vincent, 2015; Rajarajeswaran and Vishnupriya, 2009) examined the effects of exercise on physiologic and psychological functioning and quality of life of cancer patients who participated in exercise programmes. The benefits of exercise on quality of life, cancer-related fatigue, immune function and cardiovascular fitness in cancer patients were repeatedly demonstrated.

Exercise has also been associated with decreased recurrence and mortality in primary breast and colon cancer. In 2005, a seminal study of breast cancer patients exercising 9 or more hours a week experienced a 43% reduction in relative risk of breast cancer coming back and 50% relative improvement in survival (Holmes et al., 2005). Stage III colon cancer patients who exercised 18 or more hours per week had a 50% reduction from colon cancer (Meyerhardt et al., 2006). A year later, exercise was found to alleviate many of the side effects associated with the diagnosis and treatment of cancer thus improving patient’s physical and psychosocial quality of life (QOL). Results of a 3-year study of 933 breast cancer patients indicated a 64% reduction in risk of death if exercising at moderate intensity for 9 hours weekly (Irwin et al., 2008). A review of eight studies corroborated the work of the aforementioned researchers, reporting an improved 50% survival rate among patients with breast cancer who exercise 8–9 metabolic equivalents per week (Bouillet et al., 2015).

Aging is associated with increased risk of developing cancer; 86% of all cancers occur in persons over the age of 50 years (American Cancer Society, 2016). Along with the increased risk of developing cancer, elderly women also deal with the other normal effects of aging, including changes in skin, vision and hearing, bone loss and a slowing metabolism. These normal changes of aging are often accompanied by co-morbidities, such as diabetes, heart disease and arthritis.

Approximately one in five US citizens will be elderly by 2030 (National Institute of Health, n.d.). Falls and mobility disorders are two of the most common and serious problems facing older adults. Falls and instability cause considerable morbidity and mortality and can lead to reduction in function, especially skills related to activities of daily living (ADLs). Balance and mobility impairments have been modified by various exercise interventions in some populations, often in nursing home or assisted living patients, but less attention has focused on fall prevention and mobility training in community dwelling older adults (Arnold et al., 2008). Blair and colleagues (2016) examined the association between physical inactivity and QOL in elderly cancer survivors in their seventies and eighties, and similar-aged women without cancer. They found that inactive women cancer survivors reported a poorer QOL than did cancer survivors who remained physically active. The physically-active cancer survivors reported QOL similar to women without cancer.

While the benefits of exercise are evident, exercise is still not a standard of care for persons with cancer. In early 2010, the American College of Sports Medicine (ACSM) published exercise guidelines for cancer patients during and after treatments. At the June 2010 American Society of Clinical Oncology (ASCO) meeting, a panel of experts recommended using the ACSM exercise guidelines as an important treatment component for patients. Yet fewer than 20% of cancer survivors are meeting the recommended physical activity guidelines. In general, females and the elderly are less likely to participate in exercise (Snyder et al., 2009; Zahran et al., 2005). The lack of providers skilled in guiding exercise for this specialised population is one of the barriers to the development of exercise programmes for persons with cancer and to meeting ACSM guidelines.

The purposes of this study were to (a) test the effects of eight weeks of resistive, aerobic and balance exercise training on functional tests, fatigue and QOL, and (b) to examine how the exercise programme impacted activities of daily living among women over the age of 55 years with a history of cancer. Results of this study will contribute to the body of evidence required to develop evidence-based interventions. Results may also provide guidance to nurses when counselling elderly women with cancer about the benefits of exercise as part of cancer treatment.

Research questions

Guided by Bandura’s social cognitive theory (1986), the study examined the impact of a group exercise intervention on physical functioning. Social cognitive theory posits a triadic reciprocation among person, environment and behaviour. In this study, person was represented by self-reported QOL; a group exercise with individual student trainers represented environment; behaviour was represented by physical functioning. Specific research questions included the following:

What is the effect of an 8-week monitored exercise programme on the physical functioning of older women cancer survivors?

What is the effect of an 8-week monitored exercise programme on cancer-related fatigue among older women cancer survivors?

What is the effect of an 8-week monitored exercise programme on quality of life of older women cancer survivors?

What insights do qualitative findings provide to further understand the quantitative results?

Design

A sequential explanatory mixed methods design was used to explore the effects of a structured, monitored exercise programme on older women with cancer. The quantitative strand examined the effects of the exercise programme on objective outcomes, including endurance, strength, flexibility, balance, fatigue and quality of life. Triggered by the marked improvement in participants’ performance and intrigued by anecdotal stories shared by one of the participant’s daughters, a subsequent qualitative strand explored how these changes impacted the women’s daily functioning and quality of life. The rationale for this design is that traditional quantitative findings only provide a statistical measure of improvement. The qualitative strand provided rich data that provided insight into how those improvements translated into the participants’ everyday life.

Methods

Sample

Inclusion criteria for the study included being female, over the age of 55 years, with a history of cancer and physician referral. Following Institutional Review Board (IRB) approval, a convenience sample of 17 women, ranging in age from 56–90 years (M=69.4) with varying degrees of physical fitness, with a history of cancer participated in the quantitative strand of the study. All of these women had experienced some form of cancer within the past 20 years, including breast (n = 11), skin (n = 3), pancreatic (n = 1), colon (n = 1) and thyroid (n = 1). All were post-treatment (e.g. chemotherapy and radiation therapy) and one woman was 5-weeks post-mastectomy at the start of the exercise programme. Several of the women reported experiencing symptoms of peripheral neuropathy and depression during and following their cancer treatment. Three dropped out during the exercise training due to medical reasons, leaving a final sample of 14 women in the quantitative strand of the study. Following completion of the quantitative strand, an amended proposal to add the qualitative strand was submitted and approved by the IRB. All 14 women completing the quantitative strand were invited to participate in the qualitative portion of the study. Of these, a subset of nine women consented to be interviewed for the qualitative strand; ages of the subset ranged from 56–90 years with a mean age of 70 years. Two of the participants exercised regularly, and one of these was a retired physical therapist who still volunteered her time as an assistant with an exercise class at a local junior college.

Instrumentation

The quantitative strand of the study incorporated multiple objective measures that assessed participants’ physical characteristics, strength, aerobic fitness, balance and fall risk, and functional tests for independent living. Assessments were selected on the recommendation of one of the study investigators who is an ACSM Fellow and has published extensively in this area. All tests were conducted according to the ACSM guidelines (2010). Subjective data included self-reported surveys of cancer-related fatigue and quality of life.

Physical characteristics

Body weight was measured in pounds on a digital scale (Heath-O- Meter, model 498KL); standing height was measured in inches on a free-standing stadiometer (Seca, model 0123). Pre-exercise blood pressures were assessed with a digital cuff (Omron Series 5, Model HEM712C).

Strength

Ten resistive weight stations (five upper body stations and five lower body stations) were used to assess strength. One repetition maximum (1-RM), the maximum weight a participant could comfortably lift one time, was obtained at all 10 stations. The five upper body measurements and the muscle groups assessed included (a) biceps curl (biceps), (b) lateral (lat) pull (latissimus dorsi, biceps, trapezius, rhomboids and posterior deltoid), (c) chest press (pectoralis, deltoid and triceps), (d) back extension (posterior shoulder-girdle muscles and upper body posture muscles) and (e) mountain (mt) low row (latissimus dorsi, biceps, trapezius, rhomboids and posterior deltoid). Lower body measurements included (a) seated leg curl, (hamstrings), (b) seated leg extension (quadriceps), (c) seated double leg press (quadriceps hamstrings and gluteals), (d) hip abductor (abductors) and (e) hip adductors (adductors). 1-RM testing was done on two subsequent days in order to obtain the most stable values on which to base exercise prescriptions, which served as the basis for starting workouts at 40% of this value.

Aerobic fitness

The 6-minute walk test was performed on the indoor track at the university fitness centre as a measure of aerobic fitness. Each lane was marked off in 1/8 mile segments. The total distance achieved was recorded in feet. The 2-minute stepping in place test was also used to measure aerobic fitness. Participants stepped in place with thighs touching an adjustable rope placed across the stepping area.

Balance and fall risk

The Biodex Balance System used for balance testing consisted of three 20-second trials and quantified sway scores by age groups. The fall risk test was used to assess balance and consisted of three 20-second trials interspersed with 10 seconds of rest. During each trial, participants attempted to keep a small ball aligned in a circle while the bed of the machine moved slightly from front to back and from side to side. The three scores were averaged and displayed as an actual score and standard deviation score and compared to age norms. A lower score indicated better balance than a higher score.

Functional tests related to ADLs

In the 30-second chair stand, participants were instructed to sit in an armless chair with arms across chest, then fully stand to complete height and repeat this as many times as possible within the time allotted. For the 30-second arm curl, participants sat in a chair holding a five-pound weight in the dominant hand with the arm fully extended. The non-dominant arm was fully extended at the side of the body. Participants then curled the weight towards the chest as many times as possible in the prescribed time frame of 30 seconds. The 8-feet up and go test measured gait mobility. From a seated position, participants stood, walked 8 feet, made a 180° turn, walked back to the chair, turned and sat down again. The time in seconds that it took to perform the test was recorded. Participants needing to use hands to push off from the chair in order to get up were not disqualified from the test but the time was adversely affected. Prior to performing the back-scratch test, an 8½ × 11 inch piece of onion-skin paper was attached to the clothing on the participant’s back. To measure arm and shoulder flexibility, participants reached over the shoulder with one arm and behind the back with the other arm to determine whether the middle fingers could touch each other. The number of inches of overlap is a (+) score; the fingers touching a (0) score, and inches between fingers a (–) score.

The chair sit and reach test measures the flexibility of upper and lower legs. The test was performed while participants were seated in a chair with shoes off, leaning forward with one leg fully extended and stretching with both hands held together using the middle fingers to reach as close as possible to the toes. This test was performed with shoes off while seated, but leaning forward with one leg fully extended and stretching with both hands held together using the middle fingers to reach as close as possible to the toes. A cardboard measuring device marked off in minus (–) inches, zero (0) and plus (+) inches was used to measure the reach obtained. Participants were allowed to do this test with both legs and the best score obtained was used.

Cancer-related fatigue and quality of life

Cancer-related fatigue was measured at baseline and on the final day of class, using the 13-item Functional Assessment of Chronic Illness-Fatigue, version 4.0 (FACIT-F), written at the 4th grade reading level. Respondents indicated agreement with each statement based on a ‘0’ (not at all) to ‘4’ (very much) scale. Eleven items were reverse scored. Individual items were summed, multiplied by 13, and divided by the number of items answered. Missed items were not calculated into the fatigue subscale score. The range of possible scores is 0–52, with higher scores indicating less fatigue and better quality of life. Internal consistency estimates as determined by Cronbach’s alpha range from 0.93–0.95.

QOL

This was measured at baseline and on the last day of class using the Functional Assessment of Cancer Therapy-General, Version 4.0 (FACT-G), a 27-item instrument with four primary quality of life domains: Physical well-being (seven items), Social/family well-being (seven items), Emotional well-being (six items) and Functional well-being (seven items). Each item was rated on a scale ranging from ‘0’ (not at all) to ‘4’ (very much). Items were reverse scored as indicated, summed and multiplied by number of items in the subscale and then divided by the number of items answered. Subscale scores range from 0–24 (Emotional well-being) and 0–28 (Physical well-being, Social/family well-being and Functional well-being). Subscale scores were summed to provide a total FACT-G score. Higher scores are indicative of better QOL. Reliability and validity have been established in numerous studies.

Procedures

Quantitative strand

An advertisement was placed in the local newspaper recruiting women with a history of cancer for participation in an exercise programme to be held at the university. Those interested attended an informational session on a Saturday morning. All those electing to participate were given packets that included a physician referral form that was returned by physicians, a Physical and Health History Survey completed by participants, along with written approval to engage in the study and mailed back to the researchers. Following receipt of the physician approval and the Physical and Health History Survey form, participants provided written informed consent. Prior to the first exercise session, baseline data (e.g. functional status measures and QOL) were collected.

Each participant was assigned a personal student trainer to supervise the exercise and monitor physical well-being during the exercise sessions. The students were undergraduate kinesiology students enrolled in an Aging and Physical Performance class that was adapted to the needs of this special population. These students worked under the supervision of a kinesiology faculty member with extensive experience working with older adults.

The exercise class met 2 days per week for 65-minute sessions over an 8-week period. Prior to each session, heart rate (HR) and blood pressure (B/P) were documented. The exercise programme began with a 10-minute warm-up. This was followed by 30 minutes of resistive exercise at 10 different stations and 15 minutes of aerobic and balance training. Each session concluded with a 10-minute cool down, followed by a post-session check of HR and BP. At the conclusion of the study, all functional and quality of life measures were repeated.

Qualitative strand

At the conclusion of the quantitative strand, a daughter of one of the participants commented to a member of the research team ‘You really need to be asking how this programme has affected their daily activities. Mom is a different person; I no longer have to assist her with showers!’. This comment was shared among the research team and the decision was made to continue the study to explain what the objective results meant to women in their daily lives. Following IRB approval to add a qualitative component, participants in the quantitative strand were invited to share their experiences for the qualitative strand. This study utilised qualitative description (Sandelowski, 2000) to describe the experiences of these women during and after an exercise programme, and the impact on their quality of life and activities of daily living. Participants were encouraged to explore their perceptions and experiences of the impact of the exercise programme on activities in their daily lives through a series of open-ended questions. The qualitative interview guide is displayed in Box 1.

Box 1.

Qualitative interview guide.

1. Tell me what kind of changes you saw in yourself though participation in this exercise programme.

Prompts:

a. Did you notice a difference in your stamina by the end of the programme?

b. Are there things you are able to do now that you could not do at the beginning of the study?

i. For example … (bathing/meal preparation/clean-up/general energy levels)

ii. Social activities (dining out/church/shopping/walking the dog)

2. Tell me how your mood was affected by participating in this exercise programme.

Prompts:

a. Tiredness/fatigue

b. Energy level

c. Frustration related to fatigue

d. Sadness

3. Did you experience any change in your daily routines as you progressed in the programme?

Prompts:

a. Sleep patterns?

b. Eating?

c. Pain?

4. Did you notice a change in attitude?

Prompt:

a. Were you more hopeful?

5. Did family/friends notice any differences in you?

6. Describe in one word how you felt before the exercise programme, and describe in one word how you felt after completing the exercise programme.

Participant stories were elicited through personal interviews by a member of the research team in the participants’ homes or at a designated place of mutual convenience. Interviews were guided by a global question and several prompts, and were tape-recorded and transcribed for later data analysis. Data for the study consisted of demographic data, interview data and the researchers’ notes and methodological journals (Beck, 1993).

Each study participant was assigned a number identifier, thus preserving confidentiality. Data were transcribed and saved to the principal investigator's (PI) password-protected personal computer. A second copy of the data was de-identified and used for data analysis. The code books with the participants’ names and research codes were kept in a locked file in a secured office.

Results

Quantitative strand

Statistical significance was determined at p < 0.05. Means and standard deviations (SDs) were obtained on all variables. Paired t-tests were used to determine training effects between pre- and post-test scores for the 10 resistive exercise stations, six functional tests and fall risk balance scores. Detailed findings are presented in Table 1.

Table 1.

Functional tests paired t-test.

Test	Pre-test (M/SD)	Post-test (M/SD)	t-test
Upper body strength measures
1-RM bicep curl @40%	19.06 (9.30)	25.16 (10.18)	–4.46^a
1-RM lat pull down @40%	52.78 (20.89)	71.69 (21.52)	–4.85^a
1-RM chest press @ 40%	20.00 (8.37)	25.75 (10.41)	–5.94^a
1-RM back extension @40%	50.31 (22.69)	68.44 (23.93)	–6.93^a
1-RM mountain low row @40%	34.06 (13.93)	44.38 (14.13)	–6.98^a
Lower body strength measures
1-RM leg curl at 40%	78.75 (30.96)	97.88 (27.18)	–5.67^a
1-RM leg extensions @40%	56.41 (37.08)	70.25 (35.94)	–6.08^a
1-RM seated leg press @40%	100.94 (69.00)	162.19 (68.10)	–4.88^a
1-RM abductor @40%	79.22 (33.46)	101.06 (30.16)	–5.34^a
1-RM adductor @40%	107.19 (42.85)	133.72 (35.45)	–3.42^b
Aerobic fitness
6-minute walk (in feet)	1415.63 (434.04)	1772.31 (432.27)	–10.13^a
Balance and fall risk
Fall risk test standard deviation	2.71 (1.55)	1.95 (1.07)	2.67^c
Functional tests of independent living
30-second chair stand	11.13 (3.78)	15.38 (4.97)	–6.09^a
30-second arm curl	12.81 (4.20)	17.80 (4.69)	–7.33^a
8-foot up and go	8.30 (3.41)	6.68 (2.75)	3.78^b
Back scratch	–5.19 (3.96)	–3.43 (3.39)	–4.25^a
Chair sit and reach	–3.97 (4.38)	–2.19 (4.14)	–5.28^a

1-RM: one repetition maximum; M: mean; SD: standard deviation.

Smaller M in post-test from pre-test for fall risk and 8-foot up and go indicates improved performance.

p ≤ 0.001; ^bp ≤ 0.01; ^cp ≤ 0.05.

Physical characteristics

No significant differences in weight or BP over time were noted. The pre-test mean weight (186.88 lb) was unchanged (187.0 lb). Systolic BP was also unchanged. Resting diastolic BP at post-test (70.0) was lower than baseline (75.0) but the difference was not significant.

Strength

Due to the small sample size, paired t-tests on 1-RMs reported as percentage change were significant for three upper body resistive machines (back extension 27.0%, lat pull 18.7% and mt low row 18.6%) and for three lower body resistive machines (leg extension 13.2%, seated leg press 66.4% and abductor 23.7%).

Aerobic fitness

Participants significantly increased the distance (in feet) completed in the 6-minute walk test. The average improvement over time was 15.8%.

Balance and fall risk

Results of the paired t-test on the risk fall balance test for actual score and the SD score revealed that there was no statistical improvement in balance between the pre- and post-test for these cancer survivors.

Functional tests related to activities of daily living

Paired t-tests also indicated that all functional tests except the back scratch were significant (p ≥ 0.05) as follows: 30-second chair stand (+55.9%), 30-second arm curl (+35.1%), 8-feet up and go (–22.9% faster time) and chair sit and reach (+4.5%).

Cancer-related fatigue

Cancer-related fatigue improved significantly over time. Initially women reported moderate levels of fatigue, with a mean score of 30.55 on a 0–52 scale with higher scores indicating less fatigue. At the completion of the exercise programme, fatigue scores improved to an average of 40.73. Findings are depicted in Table 2.

Table 2.

Fatigue and quality of life (QOL) paired t-test.

Test	Pre-test (M/SD)	Post-test (M/SD)	t-test
Fatigue	30.55 (15.13)	40.73 (13.07)	–4.09^a
Quality of life
Physical well-being	21.55 (6.38)	23.64 (5.03)	–2.16^b
Social well-being	24.00 (5.57)	23.14 (5.96)	2.12
Emotional well-being	17.55 (5.47)	16.91 (4.93)	1.14
Functional well-being	20.27 (6.72)	22.64 (6.10)	–2.19^b
Total QOL	77.14 (20.85)	81.14 (19.60)	–1.02

M: mean; SD: standard deviation.

p ≤ 0.01; ^bapproaching significance (0.054; 0.056).

Quality of life

There is no statistical significant change in QOL scores over time. However, the physical well-being (p = 0.056) and functional well-being (p = 0.054) subscale scores approached significance. No change was noted in the social and emotional well-being subscale scores or the total QOL score.

Qualitative strand

Data analysis was addressed in two stages: the first stage of analysis occurred during data collection, and the second stage of analysis after the interviews, between interviews and at the completion of data collection (Earlandson et al., 1993). Additionally, this study utilised qualitative description (Sandelowski, 2000) and the constant comparative method (CCM) described by Glaser and Strauss (1967) was utilised throughout the data analysis process. The CCM is a process in which each item of the data is compared to all other items within the individual data set, and compared to data items in other data sets, which allowed a defined pattern or gestalt to emerge from the data.

Transcripts were reviewed multiple times to identify categories and emerging themes in an attempt to understand the participants’ perceptions of the exercise programme. Resultant categories and themes were reviewed and verified by experienced qualitative researchers.

The nine participants in this arm of the study shared their journey of participating in the exercise programme and how the programme impacted their daily life. Four key findings emerged from the interviews:

Impact of exercise on activities of daily living

Perceived benefits of exercise: mind, body, spirit

Unspoken camaraderie/bonding

Holding on to hope.

Finding 1: Impact of exercise on activities of daily living

When asked ‘What could you do better at the end of the programme that you couldn’t do at the beginning?', participants described that improved energy level and physical stamina enabled them to do such things as shower independently, do the grocery shopping and meal preparation, and clean-up. Participant 001, a 78-year-old breast cancer survivor, reported:

I was better able to keep up with my grocery shopping … my activities related to keeping food in the house and cooked and the dishes done.

She further stated:

I always used to go back to bed after appointments, but I didn’t go back to bed [after the exercise classes]. I would go out shopping or clean or do whatever, I had a lot more energy, a lot more energy.

Participant 004, a 65-year-old breast cancer survivor, noted ‘I became stronger'. Another breast cancer survivor, Participant 007, age 56 years, similarly commented ‘I was able to greatly increase my capabilities of doing physical things. I just felt so much better'.

Two of the more elderly participants (ages 78 and 84 years) used walkers to assist with mobility, but saw the biggest changes in their ADLs. One was able to do her own housework and meal preparation after the conclusion of the class, while the other progressed to being able to shower and dress independently, whereas prior to participating in this exercise class she required assistance with all ADLs. All of the women saw greater improvement with the focused exercise regimen, including sleep patterns, stamina and mood.

Many of the women identified that their balance improved during and after the exercise programme. Participant 008, a 67-year-old with a history of breast cancer, stated ‘My walking, my feeling better … And my strength in my arms and my posture improved'. Several of the participants (008; 009, a 72-year-old pancreatic cancer survivor; and 003, a 70-year-old with history of breast cancer) shared similar sentiments, stating ‘I just feel so much better'.

Additionally, many reported some improvement in their sleep patterns, because they were not as tired at the end of the programme. Participant 007 said, ‘I think my sleeping was better during the exercise'.

Finding 2: Perceived benefits of exercise: Mind, body, spirit

Almost all participants reported that the exercise and physical activity was beneficial. These benefits are expressed from a holistic perspective of the mind, body and spirit that these participants realised. When asked to describe what kind of improvements she experienced from starting the programme to ending it, a 68-year-old with colon cancer (Participant 006) declared ‘Oh, everything improved!’.

Mind

Many participants talked about the psychological benefits experienced as a result of engaging in the exercise programme. There were several dimensions to the perceived psychological health benefits that the participants experienced: these included (a) mood improvements, (b) attitude changes and (c) determination and increased confidence.

This programme helped improve the participants’ mood and attitude, with many stating that they had a brighter outlook, more energy and motivation, and an overall feeling of normalcy. The mind–body connection was apparent when participants were asked whether they had noticed a chance in their attitude. Reports such as ‘Oh, yeah, a lot better attitude!’ (Participant 007); ‘I have a brighter outlook’; ‘But I was ready to get started getting my life back (after the cancer)’ (Participant 004).

An attitude of determination ensued as stated by one of the participants who had a family history of cancer: ‘I was determined not to let it (cancer) defeat me’ (Participant 004).

One participant did notice a huge difference in her confidence and determination:

A lot more confidence, and … I became more confident that I could do things that I wasn’t sure of before. The exercise programme pushed me to not sit back and let it [cancer] take over my life. I needed to still be in charge and it helped me there. (Participant 007)

Body

A number of physical benefits were reported. These were described in terms of increased energy, physical stamina, and balance as well as some improvement in sleep and daily activities. Many reported less fatigue and increased energy levels.

I think I had a lot more energy. Um, in fact I know I did. I used to struggle to get up in the morning … but when I started exercising … I think it gave me a lot more energy. (Participant 007)

When participants were asked to compare their physical stamina prior to the exercise programme to their physical stamina at the end of the programme, all of the women noted an increase in stamina. Participant 002, an 84-year-old with a history of skin cancer, passionately stated ‘When I had a morning appointment or something, I’d come home … go back to bed'. At the end of the programme, she reported, ‘But I didn’t go back to bed. I would go out shopping or clean or do whatever, I had a lot more energy, a lot more energy'.

The oldest participant (005), a 90-year-old with skin cancer, said that ‘I became stronger, and was able to greatly increase my capabilities of doing physical things'. Many of the women reported that their balance was improved, which improved their general mobility.

Additionally, many women reported improvement in their sleep patterns, because they were not as tired at the end of the programme. One stated, ‘I think my sleeping was better during the exercise’ (Participant 001). Another woman expressed some physical improvement in day-to-day activities, for instance ‘I was walking easier – well everything was easier’ (Participant 002). Others reported that they could go grocery shopping and felt stronger to prepare meals and participate in other routine daily activities. Their consensus was ‘I just feel so much better'.

Spirit

Prayer was an integral part for some participants. ‘There has been an occasion that, especially [name], asked if we could pray for her. But we normally, I mean, I pray for them silently. You know what I’m saying’ (Participant 009). An unexpected finding was the number of participants who engaged in daily prayer for themselves and others, and who also had ‘prayer teams’ praying for them during their cancer treatment and, as Participant 009 stated, ‘We are all in God’s hands – and all of the cancer survivors go to church'.

Finding 3: Camaraderie/bonding

A fascinating discovery was the camaraderie passionately expressed by the women. The commonalities shared were that all of the participants had been diagnosed with cancer and were either survivors or undergoing treatment at the time of the study, and were committed to participating in the exercise programme.

The intriguing aspect of the exercise programme was that the women did not have the opportunity to get to know each other on a personal level as there was little time for conversation or social interaction due to the structured nature of the exercise programme. They were all focused on their tailored exercise regimen, which was closely monitored by trained staff members, yet despite this, there was an unspoken camaraderie.

Additionally, there was a sense of loyalty among the members of the group. For example:

I didn’t know her from Adam, but I would always wait for her and she would wait for me on the steps or something going up to the walking thing [e.g. track] because we could walk the same. We would encourage each other … you know to keep walking faster. (Participant 008)

It was the unspoken bond they shared that was spoken of during of the interviews. Participant 006 described the uniqueness of this exercise programme, stating ‘It was for women over 55 and number two because it was cancer women. So we all kind of had something in common and we all kind of bonded together'. Participant 007, who was still in treatment at the time of the study said:

We did not discuss each other’s cancers, but I knew they all had cancer. And to see them and that they were on the way other side of their cancers and still living and still active and still a good attitude and all, so [that’s] the peer relation that we had. The peer interaction between the other ladies and myself, we didn’t exchange phone numbers and we don’t call and email or Facebook each other, but to see each other and know that our background all had cancer somewhere in it and yet we were there doing things.

Despite the fact that these women did not know each other personally, the camaraderie and bonding was an important and unique aspect of this exercise programme, as Participant 004 eloquently stated: ‘And, if I’m gonna exercise, I want to exercise with [these] people. I think it’s the camaraderie besides the exercise that helps a lot, that positive attitude.’

Finding 4: Holding on to hope

Another unique aspect of this exercise programme was the hope that it instilled in each participant. The participation in a supportive, monitored exercise programme instilled the feeling of ‘hope’ in the participants, and encouraged them as they saw physical and emotional improvements from participating in this monitored exercise programme. Participant 004 commented, ‘During the exercise programme I became stronger and more confident that I could do things that I wasn’t sure of before'.

Participants shared that they felt a camaraderie because of their shared diagnosis of cancer. Those women who had recently had surgery or chemotherapy were encouraged by those women who were 2, 5 or 20 years out from their cancer, which gave them hope for their own success and recovery. ‘After [the exercise programme], I was hopeful. Hopeful. Because I saw the benefit …’ (Participant 004). ‘Now, I have hope …’ (Participant 008). ‘Part of what I did with the exercise programme and with going through full reconstruction was I wanted my girls, if they ever face this, to have hope’ (Participant 004).

Comparison of results

The quantitative and qualitative findings, with regard to statistical and clinical significance, are summarised and compared in Table 3.

Table 3.

Comparison of quantitative and qualitative results.

Concept/variable	Quantitative	Qualitative
Physical fitness
Strength	Significant improvement	Clinically significant
Aerobic fitness	Significant improvement	Clinically significant
Balance and fall risk	Non-significant	Clinically significant
Functional ADLs	Significant improvement	Clinically significant
Fatigue	Significant improvement	Clinically significant
Quality of life
Physical well-being	Non-significant	Clinically significant
Social well-being	Non-significant	Clinically significant
Emotional well-being	Non-significant	Clinically significant
Functional well-being	Non-significant	Clinically significant
Total quality of life	Non-significant	Clinically significant

ADLs: activities of daily living.

Discussion

The results of this current study highlight the importance of approaching a research question using a mixed methods approach. Although the quantitative findings showed statistically significant improvement in many areas, variables that were non-significant in the quantitative strand of the study were demonstrated to be clinically significant in the qualitative strand.

Physical fitness

Strength, aerobic fitness and functional ADLs demonstrated statistically significant improvement in this sample. Participants were able to lift more weight, walk further and better engage in ADLs through increased flexibility and strength. The quantitative findings did not support statistically significant changes in balance or fall risk, in spite of improvements in strength. However, the qualitative strand of the study indicated that the effects of the exercise programme positively impacted all aspects of physical fitness, including balance. Participants reported improving in such measures as daily hygiene, grocery shopping and meal preparation/clean-up, and generally caring for themselves and their families. It is also of interest to note that while balance and fall risk were not significantly improved in the quantitative strand, women did volunteer in their qualitative interviews that they noted improvement in their balance. While the quantitative results indicated improvement in a controlled environment, the qualitative findings translated these improvements into real life activities.

Fatigue

Participants in this study reported improved fatigue on both quantitative measures and during the qualitative interviews. The qualitative interviews provided support and insight into the statistical improvement in cancer-related fatigue. Repeatedly, women spoke of having ‘more energy, a lot more energy’. This translated into spending less time in bed and being able to shop, prepare meals and clean.

QOL

Of particular interest are the results from the QOL assessments. Findings from the quantitative strand would suggest there were no improvements in QOL; however, the qualitative findings tell a very different story. This improvement was evident in the women’s mood, attitude, determination and confidence levels. Several participants reported feelings of ‘hope', noting that the exercise programme alleviated feelings of depression. Participants stated that they had a ‘brighter outlook … I’m happier’.

The self-reported quantitative QOL measure did not fully capture the magnitude of the improvements in physical, social, emotional and functional well-being. This became evident in the nuances reported by the women in the qualitative strand of the study. For example, women spoke of feeling more confident, and one woman expressed ‘I felt normal’.

The diagnosis of cancer can be devastating. The disease, coupled with treatments and their attendant severe side effects, may often cause irreparable damage to the body and the psyche which can linger long after the cancer treatment is over. It has been well documented that exercise is beneficial for people with cancer, even those who are actively undergoing treatment. This study supports previous research that demonstrates the positive effects of a monitored exercise programme in older women in both physical and mental parameters, and functional activities that impact QOL (Gerritsen and Vincent, 2015; Hanna et al., 2008; Rajarajeswaran and Vishnupriya, 2009). This mixed methods study is unique in that it has expanded on quantitative results to more fully explore the meaning of these improvements by incorporating a qualitative perspective.

Study limitations and strengths

The findings of this pilot study are limited by the small sample size. However, this limitation was offset by the strengths of the mixed methods approach. Had this study been conducted solely from the quantitative perspective, the significant improvements in participants’ QOL may have been dismissed. Conversely, approaching this solely from a qualitative standpoint would have severely limited generalisbility (Glaser, 1978; Nilsen, 2013). Utilising a mixed methods approach strengthened the results of this study. Not only were statistically significant improvements noted in three of the four physical fitness areas and fatigue, clinically significant improvements were noted in all areas of physical fitness, fatigue and QOL. The results of this study will contribute to the existing body of knowledge for exercise in cancer patients and highlight the impact of exercise on the practical applicability of everyday life.

Implications for future research

Research continues in the area of exercise for persons experiencing chronic illness; this study suggests several avenues for further investigation. Future research utilising the mixed methods approach with a larger sample size would yield more significant results contributing to the science in caring for patients with cancer. This study may be replicated for persons with other chronic illnesses, such as Parkinson’s disease or end-stage renal disease. One interesting area for future research that emerged from the qualitative data was the use of prayer and other religious practices used by cancer patients during the course of their treatment, and examine the effect this has on the disease, treatment, and survivorship.

Conclusion

In summary, use of the mixed methods approach in this pilot study enhanced the findings; clinically significant results may have been overlooked had the qualitative strand not been addressed. The overwhelming consistent consensus of the participants was that this monitored exercise programme was beneficial, and this was enthusiastically summarised by one participant, who said ‘I think it’s a good thing'.

Understanding the physical, emotional and spiritual experiences of patients with cancer who incorporate a regular exercise regimen in their lives is essential to inform the development of evidence-based interventions and to quantify the benefits of exercise and physical activity. Exercise truly does have positive effects, and healthcare professionals need to purposely incorporate exercise into their patients’ treatment regimen, and encourage their patients to participate in these programmes.

Key points for policy, practice and/or research

Inclusion of an exercise regimen into standard cancer treatment protocols is needed to have a positive impact on patient outcomes, such as reducing cancer-related fatigue and improving quality of life.

Nurses are positioned to counsel patients on the importance of including exercise as part of the cancer treatment regimen. Understanding the impact of exercise on lives of cancer patients will enhance patient and family education.

Utilisation of mixed methods research strategies provides greater depth to the study, and can yield more useful information than using a single research strategy.

Footnotes

Declaration of conflicting interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Linda L Rath, PhD, RN, is an Associate Professor whose research interests include stress, benefits of exercise in the elderly, and alternative/complementary cancer therapies across the lifespan.

Melinda Hermanns, PhD, RN, is an Associate Professor whose research interests include quality of life in persons with chronic illness, specifically Parkinson’s disease and cancer.

Joyce Ballard, PhD, Professor Emerita, has a long-standing interest in studying the effects of exercise on the health of elderly women.

Barbara K Haas, PhD, RN, is a Professor whose programme of research examines effects of exercise on patient outcomes and quality of life of persons with cancer.

References

American Cancer Society (2016) Cancer facts and figures 2016. Available at: www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf (accessed 25 May 2016).

American College of Sports Medicine (2010) Guidelines for Exercise Testing and Prescription, 8th edn. Philadelphia, PA: Lippincott Williams & Wilkins.

Arnold CM, Sran MM and Harrison EL (2008) Exercise for fall risk reduction in community-dwelling older adults: A systematic review. Physiotherapy Canada 60(4): 359–372.

Bandura

(1986) Social Foundations of Thought and Action: A Social Cognitive Theory, Englewood Cliffs, NJ: Prentice Hall.

Beck

(1993) Qualitative research: The evaluation of its credibility fittingness, and auditability. Western Journal of Nursing Research 15(2): 263–266.

Blair

Robien

Inoue-Choi

(2016) Physical inactivity and risk of poor quality of life among elderly cancer survivors compared to women without cancer: The Iowa Women’s Health Study. Journal of Cancer Survivorship 10(1): 103–112.

Bouillet

Bigard

Brami

(2015) Role of physical activity and sport in oncology: Scientific commission of the National Federation Sport and Cancer CAMI. Critical Reviews in Oncology in Hematology 94(1): 74–86.

Erlandson DA, Harris EL, Skipper BL, et al. (1993) Doing naturalistic inquiry: A guide to methods. Newbury Park, CA: Sage Publications, Inc.

Gerritsen

Vincent

(2015) Exercise improves quality of life in patients with cancer: A systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine 50(13): 796: 803.

10.

Glaser

Strauss

(1967) The Discovery of Grounded Theory: Strategies for Qualitative Research, Hawthorne, NY: Aldine.

11.

Hanna

Avila

Meteer

(2008) The effects of a comprehensive exercise program on physical function, fatigue, and mood in patients with various types of cancer. Oncology Nursing Forum 35(3): 461–469.

12.

Holmes

Chen

Feskanich

(2005) Physical activity and survival after breast cancer diagnosis. Journal of the American Medical Association 293(20): 2479–2486.

13.

Irwin

Smith

McTiernan

(2008) Influence of pre- and postdiagnosis physical activity on mortality in breast cancer survivors: The health, eating, activity, and lifestyle study. Journal of Clinical Oncology 24(26): 3958–3964.

14.

Meyerhardt

Heseltine

Niedzwiecki

(2006) Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: Findings from CALGB 89803. Journal of Clinical Oncology 24(22): 3535–3541.

15.

National Institute of Aging (n.d.) Aging in the United States: Past, present and future. United States Department of Commerce, Economics and Statistics Administration, Bureau of the Census. Available at: www.census.gov/population/international/files/97agewc.pdf (accessed 25 May 2016).

16.

Nilsen S (2013) Behaving collaboratively and getting along: A classical grounded theory of certified nurse midwives collaborating with physician in U.S. hospitals. PhD Thesis, University of Texas Medical Branch, Galveston, TX.

17.

Rajarajeswaran

Vishnupriya

(2009) Exercise in cancer. Indian Journal of Medical and Paediatric Oncology 30(2): 61–70.

18.

Sandelowski

(2000) Focus on research methods: Whatever happened to qualitative description? Research in Nursing & Health 23(4): 334–340.

19.

Snyder

Morey

Sloane

(2009) Reach out to ENhanceE Wellness in older cancer survivors (RENEW): Design, methods and recruitment challenges of a home-based exercise and diet intervention to improve physical function among long-term survivors of breast, prostate, and colorectal cancer. Psycho-Oncology 18(4): 429–439.

20.

Zahran

Kobau

Moriarty

(2005) Health-related quality of life surveillance–United States, 1993–2002. Morbidity and Mortality Weekly Report 54: 1–35.