Mehnert, A., Veers, S., Howaldt, D., Braumann, K.M., Koch, U., & Schulz, K.H. (2011). Effects of a physical exercise rehabilitation group program on anxiety, depression, body image, and health-related quality of life among breast cancer patients. Onkologie, 34, 248–253.

To investigate whether an exercise intervention reduces anxiety and depression, and improves quality of life, body image, and physical fitness in women with breast cancer

Patients were randomly assigned to the intervention or a wait list control group after a sports medicine assessment. The intervention group received structured group exercise training twice weekly for 10 weeks. Training sessions lasted 90 minutes, were done in small groups (five patients), and included two main components: (a) warm-up, dance and movement games, physiotherapeutic exercises, and relaxation, and (b) moderate walking and jogging outdoors. Patients wore heart monitors during exercise. Sessions were led by a physio- or sports medicine therapist. Outcome variables were measured at baseline and at the end of the 10-week study period.

• The study initially had 63 enrolled participants; 11 completed the 10-week program.
• Mean participant age was 51.88 ± 8.46.
• All participants were females diagnosed with breast cancer; 51.7% had stage I disease.
• Of the sample, 58.9% had breast-conserving surgery, 34.5% had lymphedema, and 1.8% had no surgery. All were entered after at least four weeks post-adjuvant treatment.
• Half of the sample did regular sports and fitness activities as part of their usual lifestyle, 77.2% were either married or in a relationship, and 26.4% had a college education.

• Single site
• Outpatient setting
• Germany

• Patients were undergoing the transition phase of care after initial treatment.
• The study has clinical applicability for late effects and survivorship.

A randomized controlled trial design was used.

• Hospital Anxiety and Depression Scale (HADS)
• European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
• Short-Form Health Survey–36 (SF-36)–German version
• Body Image Questionnaire
• Symptom Checklist–90–revised (symptom burden measure)

Anxiety declined over time in all patients (p = 0.08), and ANOVA showed a significant interaction of the intervention (p = 0.03). The effect size in anxiety with the intervention was -0.54 (95% CI -1.06 to -0.02). Depression declined over time in all patients (p = 0.02), but there was no interaction effect with the intervention. Body image improved over time in all patients (p = 0.003), and there was a significant interaction effect of group assignment (p = 0.006); however, body image at baseline was also better in the intervention group. There were no differences between groups in symptom burden or quality of life.

Participation in this exercise intervention was associated with a significant decline in anxiety.

• The study did not include an appropriate control group.
• The study had no attentional control.
• The final group of patients who completed the intervention and were analyzed was very small, only 11 patients.
• Authors reported different sample sizes in different tables and figures, suggesting the potential for issues in data analysis, and there is no discussion of reasons for missing data.
• Authors stated that the intervention was effective for depression, although the ANOVA did not demonstrate a significant group and time interaction effect on this variable, suggesting some investigator bias in discussion of results.
• Authors stated an intervention adherence rate of about 50%, but there was actually a 63% drop-out rate.

Study findings suggest that group exercise can be helpful in reducing anxiety in patients with breast cancer after completion of adjuvant treatment. These study results should be interpreted with caution given the high drop-out rate and study limitations.