Physical Activity in Women Receiving Chemotherapy for Breast Cancer: Adherence to a Walking Intervention

Karen K. Swenson

Mary Jo Nissen

Susan J. Henly

breast cancer, breast neoplasms, physical activity, exercise
ONF 2010, 37(3), 321-330. DOI: 10.1188/10.ONF.321-330

Purpose/Objectives: To describe and predict adherence to a physical activity protocol for patients with breast cancer receiving chemotherapy.

Design: Longitudinal, observational study.

Setting: Cancer center in the upper Midwestern region of the United States.

Sample: 36 patients with breast cancer aged 40-55 years who were receiving adjuvant treatment.

Methods: A longitudinal study was conducted within a randomized clinical trial comparing the effects of physical activity versus bisphosphonates on bone mineral density. Participants randomized to physical activity were advised to walk 10,000 steps per day and received initial physical therapy consultation and ongoing motivational interviewing. Multilevel modeling was used to identify variables that predict adherence.

Main Research Variables: Adherence to the 10,000-step protocol was estimated with total steps and mean steps per day.

Findings: Thirty-six women were enrolled in the physical activity group; 29 provided step data. The mean total steps per participant for the first six weeks was 280,571 (SD = 111,992), which is 67% of the prescribed steps. Excluding days when no steps were recorded, the mean steps per day for the initial six-week period was 7,363 (SD = 2,421), a 74% adherence rate. A significant linear increase occurred in steps per day after chemotherapy in a treatment cycle (p < 0.0001). Baseline inactivity predicted adherence.

Conclusions: Adherence to the walking program was compromised during chemotherapy but improved after chemotherapy completion.

Implications for Nursing: Knowing that chemotherapy predicts adherence to a walking protocol is useful for selecting the type, timing, and intensity of physical activity interventions.

Jump to a section


    Abrahamson, P. E., Gammon, M. D., Lund, M. J., Britton, J. A., Marshall, S. W., Flagg, E. W., … Coates, R. J. (2006). Recreational physical activity and survival among young women with breast cancer. Cancer, 107, 1777-1785. doi: 10.1002/cncr.22201
    Adjuvant therapy for breast cancer. (2000). National Institutes of Health Consensus Statement, 17(4), 1-23.
    Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211.
    Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: Freeman.
    Bines, J., Oleske, D. M., & Cobleigh, M. A. (1996). Ovarian function in premenopausal women treated with adjuvant chemotherapy for breast cancer. Journal of Clinical Oncology, 14, 1718-1729.
    Blanchard, C. M., Baker, F., Denniston, M. M., Courneya, K. S., Hann, D. M., Gesme, D. H., … Kennedy, J. S. (2003). Is absolute amount or change in exercise more associated with quality of life in adult cancer survivors? Preventive Medicine, 37, 389-395. doi: 10.1016/S0091-7435(03)00150-6
    Bravata, D. M., Smith-Spangler, C., Sundaram, V., Gienger, A. L., Lin, N., Lewis, R., … Sirard, J. R. (2007). Using pedometers to increase physical activity and improve health: A systematic review. JAMA, 298, 2296-2304. Retrieved from
    Cauley, J. A., LaPorte, R. E., Sandler, R. B., Schramm, M. M., & Kriska, A. M. (1987). Comparison of methods to measure physical activity in postmenopausal women. American Journal of Clinical Nutrition, 45, 14-22. Retrieved from
    Cleeland, C. S., Mendoza, T. R., Wang, X. S., Chou, C., Harle, M. T., Morrissey, M., & Engstrom, M. C. (2000). Assessing symptom distress in cancer patients: The M. D. Anderson Symptom Inventory. Cancer, 89, 1634-1646. doi: 10.1002/1097-0142(20001001)89:7<1634::AID-CN CR29>3.0.CO;2-V
    Collins, L. M. (2006). Analysis of longitudinal data: The integration of theoretical model, temporal design, and statistical model. Annual Review of Psychology, 57, 505-528. doi: 10.1146/annurev.psych.57.102904.190146
    Courneya, K. S. (2003). Exercise in cancer survivors: An overview of research. Medicine and Science in Sports and Exercise, 35, 1846-1852. doi: 10.1249/01.MSS.0000093622.41587.B6
    Courneya, K. S., Blanchard, C. M., & Laing, D. M. (2001). Exercise adherence in breast cancer survivors training for a dragon boat race competition: A preliminary investigation. Psycho-Oncology, 10, 444-452. doi: 10.1002/pon.524
    Courneya, K. S., & Friedenreich, C. M. (1997). Relationship between exercise during treatment and current quality of life among survivors of breast cancer. Journal of Psychosocial Oncology, 15(3/4), 35-57.
    Courneya, K. S., Friedenreich, C. M., Quinney, H. A., Fields, A. L., Jones, L. W., & Fairey, A. S. (2004). Predictors of adherence and contamination in a randomized trial of exercise in colorectal cancer survivors. Psycho-Oncology, 13, 857-866. doi: 10.1002/pon.802
    Courneya, K. S., Friedenreich, C. M., Sela, R. A., Quinney, H. A., & Rhodes, R. E., (2002). Correlates of adherence and contamination in a randomized controlled trial of exercise in cancer survivors: An application of the theory of planned behavior and the five factor model of personality. Annals of Behavioral Medicine, 24, 257-268.
    Courneya, K. S., Segal, R. J., Reid, R. D., Jones, L. W., Malone, S. C., Venner, P. M., … Wells, G. A. (2004). Three independent factors predicted adherence in a randomized controlled trial of resistance exercise training among prostate cancer survivors. Journal of Clinical Epidemiology, 57, 571-579. doi: 10.1016/j.jclinepi.2003.11.010
    Croteau, K. A. (2004). A preliminary study on the impact of a pedometer-based intervention on daily steps. American Journal of Health Promotion, 18, 217-220.
    Croteau, K. A., Richeson, N. E., Farmer, B. C., & Jones, D. B. (2007). Effect of a pedometer-based intervention on daily step counts of community-dwelling older adults. Research Quarterly for Exercise and Sport, 78, 401-406.
    Crouter, S. E., Schneider, P. L., Karabulut, M., & Bassett, D. R., Jr. (2003). Validity of 10 electronic pedometers for measuring steps, distance, and energy cost. Medicine and Science in Sports and Exercise, 35, 1455-1460. doi: 10.1249/01.MSS.0000078932.61440.A2
    Friedman, L. M., Furberg, C. D., & DeMets, D. L. (1998). Fundamentals of clinical trials (3rd ed.). New York, NY: Springer.
    Henly, S. J. (2007). Lost in time. The person in nursing research [Editorial]. Nursing Research, 56(3), 147.
    Holmes, M. D., Chen, W. Y., Feskanich, D., Kroenke, C. H., Colditz, G. A. (2005). Physical activity and survival after breast cancer diagnosis. JAMA, 293, 2479-2486. Retrieved from
    Horner, M. J., Ries, L. A. G., Krapcho, M., Neyman, M., Aminou, R., Howlader, N., … Edwards, B. K. (Eds.). (2009). SEER cancer statistics review, 1975-2006, Retrieved from
    Ingram, C., Courneya, K. S., & Kingston, D. (2006). The effects of exercise on body weight and composition in breast cancer survivors: An integrative systematic review. Oncology Nursing Forum, 33, 937-947. doi: 10.1188/06.ONF.937-950
    Irwin, M. L., Crumley, D., McTiernan, A., Bernstein, L., Baumgartner, R., Gilliland, F. D., … Ballard-Barbash, R. (2003). Physical activity levels before and after a diagnosis of breast carcinoma: The Health, Eating, Activity, and Lifestyle (HEAL) study. Cancer, 97, 1746-1757. doi: 10.1002/cncr.11227
    Iwane, M., Arita, M., Tomimoto, S., Satani, O., Matsumoto, M., Miyashita, K., & Nishio, I. (2000). Walking 10,000 steps/day or more reduces blood pressure and sympathetic nerve activity in mild essential hypertension. Hypertension Research, 23, 573-580.
    Jemal, A., Siegel, R., Ward, E., Hao, Y., Xu, J., & Thun, M. J. (2009). Cancer statistics, 2009. CA: A Cancer Journal for Clinicians, 59, 225-249. doi: 10.3322/caac.20006
    Kolden, G. G., Strauman, T. J., Ward, A., Kuta, J., Woods, T. E., Schneider, K. L., … Mullen, B. (2002). A pilot study of group exercise training (GET) for women with primary breast cancer: Feasibility and health benefits, Psycho-Oncology, 11, 447-456. doi: 10.1002/pon.591
    McAuley, E., Jerome, G. J., Elavsky, S., Marquez, D. X., & Ramsey, S. N. (2003). Predicting long-term maintenance of physical activity in older adults. Preventive Medicine, 37, 110-118. doi: 10.1016/S0091-7435(03)00089-6
    Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York, NY: Guillford Press.
    Mock, V., Dow, K. H., Meares, C. J., Grimm, P. M., Dienemann, J. A., Haisfield-Wolf, M. E., … Gage, I. (1997). Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncology Nursing Forum, 24, 991-1000.
    Mock, V., Pickett, M., Ropka, M. E., Muscari Lin, E., Stewart, K. J., Rhodes, V. A., … McCorkle, R. (2001). Fatigue and quality of life outcomes of exercise during cancer treatment. Cancer Practice, 9, 119-127. doi: 10.1046/j.1523-5394.2001.009003119.x
    National Center for Health Statistics. (2008). Chartbook on trends in the health of Americans. Health, United States, 2008. Hyattsville, MD: Public Health Service.
    Paffenbarger, R. S., Jr., Blair, S. N., Lee, I. M., & Hyde, R. T. (1993). Measurement of physical activity to assess health effects in free-living populations. Medicine and Science in Sports and Exercise, 25, 60-70.
    Pickett, M., Mock, V., Ropka, M. E., Cameron, L., Coleman, M., & Podewils, L. (2002). Adherence to moderate-intensity exercise during breast cancer therapy. Cancer Practice, 10, 284-292. doi: 10.1046/j.1523-5394.2002.106006.x
    Pierce, J. P., Stefanick, M. L., Flatt, S. W., Natarajan, L., Sternfeld, B., Madlensky, L., … Rock, C. L. (2007). Greater survival after breast cancer in physically active women with high vegetable-fruit intake regardless of obesity. Journal of Clinical Oncology, 25, 2345-2351. doi: 10.1200/JCO.2006.08.6819
    Pinto, B. M., & Maruyama, N. C. (1999). Exercise in the rehabilitation of breast cancer survivors. Psycho-Oncology, 8(3), 191-206. doi: 10.1002/(SICI)1099-1611(199905/06)8:3<191::AID-PON355>3.0.CO;2-T
    Raudenbush, S. W., & Bryk, A. S. (2002). Applications in the study of individual change. In Hierarchical linear models (pp. 160-204). Thousand Oaks, CA: Sage.
    Santacroce, S. J., Maccarelli, L. M., & Grey, M. (2004). Intervention fidelity. Nursing Research, 53(1), 63-66.
    Schwartz, A. L. (1998). The Schwartz Cancer Fatigue Scale: Testing reliability and validity. Oncology Nursing Forum, 25, 711-717.
    Schwartz, A. L. (1999). Fatigue mediates the effects of exercise on quality of life. Quality of Life Research, 8, 529-538.
    Schwartz, A. L. (2000a). Daily fatigue patterns and effect of exercise in women with breast cancer. Cancer Practice, 8, 16-24. doi: 10.1046/j.1523-5394.2000.81003.x
    Schwartz, A. L. (2000b). Exercise and weight gain in breast cancer patients receiving chemotherapy. Cancer Practice, 8, 231-237. doi: 10.1046/j.1523-5394.2000.85007.x
    Schwartz, A. L., Winters-Stone, K., & Gallucci, B. (2007). Exercise effects on bone mineral density in women with breast cancer receiving adjuvant chemotherapy. Oncology Nursing Forum, 34, 627-633. doi: 10.1188/07.ONF.627-633
    Segal, R., Evans, W., Johnson, D., Smith, J., Colletta, S., Gayton, J., … Reid, R. (2001). Structured exercise improves physical functioning in women with stages I and II breast cancer: Results of a randomized controlled trial. Journal of Clinical Oncology, 19, 657-665. Retrieved from
    Stel, V. S., Smit, J. H., Pluijm, S. M., Visser, M., Deeg, D. J.,& Lips, P. (2004). Comparison of the LASA Physical Activity Questionnaire with a 7-day diary and pedometer. Journal of Clinical Epidemiology, 57, 252-258. doi: 10.1016/j.jclinepi.2003.07.008
    Teixeira, P. J., Going, S. B., Houtkooper, L. B., Cussler, E. C., Martin, C. J., Metcalfe, L. L., … Lohman, T. G. (2002). Weight loss readiness in middle-aged women: Psychosocial predictors of success for behavioral weight reduction. Journal of Behavioral Medicine, 25, 499-523. doi: 10.1023/A:1020687832448
    Wankel, L. M., Yardley, J. K., & Graham, J. (1985). The effects of motivational interventions upon the exercise adherence of high and low self-motivated adults. Canadian Journal of Applied Sports Sciences, 10(3), 147-156.
    Ware, J. E., Jr., & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30, 473-483.
    Yarbro, C. H., Frogge, M. H., & Goodman, M. (Eds.). (2005). Cancer nursing: Principles and practice (6th ed.). Sudbury, MA: Jones and Bartlett.